UNIVERSITY  OF  CALIFORNIA 
'  IFORNIA  COLLEGE  OF  MEDICINE 
IIRRARY 

JUN    81971 

IRVINE,  CALIFORNIA  92664 


VENEREAL  DISEASES 


THEIR 


COMPLICATIONS  AND  SEQUELJB 


EDWARD  L.  KEYES,  A.M.,  M.D. 

Late  Professor  of  Dermatology  and  Genito-Urinary  Surgery  in  the  Believue 

Hospital  Medical  College ;  Consulting  Surgeon  to 

Believue  Hospital,  etc.,  etc. 


CHARLES  H.  CHETWOOD,  M.D. 

Professor  of  Genito-Urinary  Surgery  in  the  New  York  Polyclinic  College 

and  Hospital ;  Visiting  Surgeon  to  Believue 

Hospital,  etc. 


ILLUSTRATED  BY  EIGHT  FULL-PAGE  PLATES  IN  BLACK  AND  COLORS  AND 
ONE  HUNDRED  AND  SEVEN  ENGRAVINGS 


NEW  YORK 
WILLIAM  WOOD  AND   COMPANY 

MDCCCC 


100 


COPYEIGHT,  1900 

By  WILLIAM  WOOD  AND  COMPANY 


PREFACE. 


A  FORMER  work  of  identical  title,  from  the  pen  of  the  senior  author  of 
this  volume,  appeared  in  January,  1880,  twenty  years  ago,  as  one  of 
"  Wood's  Library."  It  had  two  objects  in  view,  both  of  which  have  been 
accomplished. 

The  first  object  was  to  combat  the  then  raging  furor  for  anterior  ure- 
throtomy  which  possessed  the  younger  members  of  the  profession.  This 
is  now  happily  over,  and  a  certain  amount  of  good  has  followed  the  ex- 
cess. Strictures  of  the  pendulous  urethra  are  understood  and  managed 
better  to-day  than  twenty  years  ago. 

The  second  and  most  important  object  was  to  disseminate  the  author's 
teachings  upon  the  treatment  of  syphilis.  This  tonic  treatment,  by  the 
prolonged  mild  use  of  mercury  in  such  a  way  as  to  do  the  patient  no  harm 
while  his  malady  was  being  mastered,  is  to-day  so  widely  spread  and  so 
well  understood,  and  has  been  accepted  so  largely,  if  judgment  be  ren- 
dered according  to  the  evidence  at  command,  that  there  is  no  reason  to 
make  any  radical  change,  in  so  far  as  syphilis  is  concerned,  in  the  presen- 
tation of  this  subject. 

But  that  book  has  long  since  ceased  to  be  a  safe  guide  in  its  urethral 
teachings  on  account  of  the  strides  made  in  bacteriology  and  therapeutics 
during  the  last  decade. 

The  younger  blood  of  the  junior  author  and  his  point  of  view,  together 
with  a  general  growing  experience,  have  revolutionized  many  of  the  ideas 
advanced  in  the  former  treatise,  and  the  time  has  seemed  ripe  to  us  to  join 
hands  in  authorship  for  the  purpose  of  placing  the  result  of  our  com- 
bined experience  before  the  profession  in  a  practical  way. 

This  volume  is  the  result. 

In  it  is  reproduced  the  senior  author's  original  teaching  concerning 
chancroid  and  syphilis,  the  latter  practically  in  the  whole  piece  making 
little  change  further  than  to  cut  out  references  and  cases  to  reduce  the 
volume  of  the  text,  but  the  chapter  on  chancroid  has  been  reconstructed. 

A  valuable  chapter  on  nervous  syphilis  has  been  contributed  by  Dr. 
Pearce  Bailey,  consulting  neurologist  at  St.  Luke's  Hospital,  and  to  him 
the  authors  render  public  acknowledgment.  Dr.  Chetwood,  the  junior 
author,  has  so  entirely  remodelled  and  rewritten  that  portion  of  the  book 


yi  PREFACE. 

relating  to  the  urethra  that  it  has  seemed  proper  to  place  this  section 
first  and  to  issue  the  volume  as  a  new  book  rather  than  under  the  name  of 
a  second  edition  of  the  old  book. 

The  authors'  warm  thanks  are  extended  to  Dr.  F.  M.  Jeffries,  direc- 
tor of  the  laboratory  of  the  New  York  Polyclinic  College  and  Hospital, 
for  excellent  work  in  collecting  references  and  assisting  in  preparing  the 
section  on  the  Bacteriology  of  Urethritis.  To  Dr.  A.  F.  Biichler  we  are 
indebted  for  clinical  material,  and  to  Dr.  D.  A.  Sinclair  for  various  good 
offices.  E.  L.  KEYES. 

C.  H.  CHETWOOD. 
109  EAST  THIBTT-FOUKTH  STREET, 
.    NEW  YORK,  January,  1900. 


CONTENTS. 


PAGE 

INTRODUCTION, ...ix 

PART   I. 

ACUTE  AND  CHRONIC  UBETHEITIS.    COMPLICATIONS  AND  SEQUELS. 

CHAPTER  I. 

Specific  and  Non-Specific  Urethritis :  Gonorrhoea.     Definition,  Etiology,  Bac- 
teriology, Symptoms,  Diagnosis,  Duration,  Treatment,       ....      3 

CHAPTER  II. 

Chronic  Urethritis :  Etiology,  Pathology,  Symptoms,  Diagnosis,  Treatment,       .    37 

CHAPTER   III. 

Balanitis  and  Posthitis — Herpes  Progenitalis — Venereal  Warts,  .        .        .        .64 

CHAPTER   IV. 

Inflammation  of  Urethral  Follicles — Peri-urethral  Abscess — Cowperitis — Pros- 
tatitis — Seminal  Vesiculitis,  .........    68 

CHAPTER   V. 
Acute  and  Chronic  Cystitis — Epididymitis, 89 

CHAPTER   VI. 

Stricture  of  the  Urethra, 107 

CHAPTER   VII. 

Gonorrhceal  Rheumatism — Non-specific  Affections  of  the  Eye — Purulent  Oph- 
thalmia,   157 

PART   II. 

CHANCROID  AND  SYPHILIS. 
CHAPTER  I. 

Chancroid :  Definition,  Etiology,  and  Clinical  History,       .  .        .        .  167 

CHAPTER   II. 

Chancroid  (Continued) :  Diagnosis,  Prognosis,  and  Treatment,     ....  177 


CONTENTS. 
CHAPTER  III. 

PAGE 

The  Complications  of  Chancroid, 186 

CHAPTER  IV. 
Syphilis :  Definition— Origin— Course— General  Pathology,         .        .        .        .198 

CHAPTER   V. 
The  Transmission  of  Syphilis :  Methods  of  Contagion— Prognosis,  .        .  203 

CHAPTER   VI. 
The  Chancre— Primary  Lesion  of  Syphilis,  ......  .  211 

CHAPTER  VII. 

Constitutional  Syphilis — Stages  of  the  Disease,    .  .        ,        .        .        .  220 

CHAPTER   VEIL 
The  General  Treatment  of  Syphilis, 224 

CHAPTER  IX. 
The  General  Treatment  of  Syphilis  (Continued),  .......  251 

CHAPTER  X.    ' 
Syphilis  of  the  Skin, 261 

CHAPTER  XI. 

Syphilis  of  the  Mucous  Membranes,  Lymphatic  Glands,  Hairy  Parts,  and  Nails,  284 

CHAPTER  XII. 
Syphilis  of  Muscles,  Tendons,  and  Aponeuroses,  Bursse,  Joints,  and  Bones,        .  292 

CHAPTER  XIII. 
Syphilis  of  the  Viscera, 302 

CHAPTER   XIV. 
Syphilis  of  the  Nervous  System, 812 

CHAPTER  XV. 
Syphilis  of  the  Genito-Urinary  Organs  in  Both  Sexes,          .        .        .        ,        .  324 

CHAPTER  XVI. 
Syphilis  of  the  Eye  and  Ear, 330 

CHAPTER  XVIL 
Inherited  Syphilis,         ....  .  336 


INTRODUCTION. 


A  STKICT  application  of  the  title  of  this  treatise  should  include  only 
-*--*-  those  diseases  acquired  during  sexual  intercourse  and  starting  in  the 
sexual  organs.  But  these  maladies  may  by  direct  contagion  make  their 
initial  appearance  elsewhere,  and  through  their  complications  and  sequelae 
invade  the  adjacent  organs  or  involve  remote  parts  of  the  body. 

Of  the  three  principal  divisions  of  venereal  disease — syphilis,  chan- 
croid, and  gonorrhoea — the  first  two  commonly  appear  upon  the  external 
genitals,  while  the  last  is  essentially  a  disease  of  the  urethra,  and  is,  on 
ac.count  of  its  microbic  origin,  otherwise  known  as  specific  urethritis. 

Each  of  these  maladies  is  distinct  from  the  other  etiologically,  path- 
ologically, and  clinically.  All  of  them  are  virulent  and  contagious,  and 
while  they  never  arise  de  novo,  yet  in  the  case  of  chancroid  and  gonor- 
rhoea there  exist  spurious  examples  which  bear  so  close  a  resemblance  to 
the  real  malady  that  the  difference  is  only  bacterial,  and  the  selection  of 
treatment  must  depend  upon  a  knowledge  of  this  fact.  These  spurious 
cases  are  of  idiopathic  origin  and  may  be  non-venereal  in  their  nature, 
but  as  they  are  frequently  acquired  during  the  sexual  act  and  so  closely 
resemble  their  prototypes  as  often  to  be  mistaken  for  them,  their  con- 
sideration becomes  a  necessity  in  a  work  upon  venereal  diseases.  The 
same  remark  applies  also  to  the  complications  and  sequelae  of  the  vene- 
real diseases.  These  latter  are  not  confined  to  the  genital  regions,  but 
include,  through  contiguity,  the  neighboring  organs  and,  by  reinoculation 
and  metastases,  remote  parts  of  the  body. 

Finally,  syphilis  is  not  a  disease  of  any  organ  or  of  any  region,  but 
of  every  tissue  in  the  body  and  of  the  blood  as  well.  Hence  the  title 
venereal  refers  only  to  the  source  from  which  these  several  maladies  and 
their  complications  are  derived  and  to  the  customary  location  of  the  pri- 
mary lesions  occasioning  them ;  but  as  the  name  is  sanctioned  by  time  and 
custom  it  must  be  retained,  although  entirely  too  narrow  to  indicate  the 
scope  of  a  treatise  which  a  proper  consideration  of  the  group  of  maladies 
involved  necessarily  calls  for. 


PART  I. 

ACUTE  AND  CHRONIC  URETHRITIS. 

COMPLICATIONS  AND  SEQUELAE. 


VENEREAL  DISEASES. 


CHAPTER  I. 

SPECIFIC    AND   NON-SPECIFIC   UKETHEITIS— GONORKHCEA. 

DEFINITION  AND  ETIOLOGY. 

THE  term  urethritis,  without  qualification,  signifies  inflammation  of 
any  portion  of  the  urethral  canal.  Such  inflammation  is  designated, 
according  to  its  cause,  specific  or  non-specific;  according  to  its  locality 
anterior  or  posterior ;  and,  according  to  its  duration,  acute  or  chronic. 

Specific  urethritis,  commonly  spoken  of  as  gonorrhoea,  is,  in  the  male, 
an  intense  urethral  inflammation,  characterized  by  a  period  of  incubation, 
and  by  a  profuse  discharge  of  pus  which  possesses  virulent  qualities,  due 
to  the  presence  of  a  diplococcus — the  gonococcus  of  Neisser. 

This  definition  at  once  places  gonorrhoea  in  the  rank  of  virulent  dis- 
eases. It  has  a  period  of  incubation,  runs  a  course  of  varied  length, 
possesses  its  virulence  to  the  very  end,  and  is  in  the  highest  degree 
contagious. 

Non-specific  urethritis,  as  its  name  implies,  differs  from  gonorrhoea  in 
that  it  is  not  referable  to  a  single  cause.  It  is  etiologically  complex. 
Its  causes  arise  from  without  and  from  within  the  urethra.  Generally 
speaking,  it  comprises  those  cases  of  urethral  inflammation  not  directly 
traceable  to  the  gonococcus.  It  may  resemble  gonorrhoea  so  closely  in 
all  its  symptoms  that,  clinically,  a  diagnosis  between  them  often  can- 
not by  any  possibility  be  made.  This,  however,  is  simply  due  to  the 
fact  that  the  symptoms  of  inflammation  of  the  urethra,  when  they  run 
high,  are  alike,  whether  their  cause  be  specific  or  non-specific.  Theo- 
retically, a  distinction  must  be  recognized  between  non-specific  urethritis 
and  gonorrhoea,  although  practically  such  a  difference  oftentimes  cannot 
be  demonstrated  except  by  resort  to  the  microscope.  Clinically  the 
symptoms  of  non-specific  inflammation  of  the  urethra  have  to  be  treated 
symptomatic  ally  in  accordance  with  the  grade  of  their  intensity ;  whereas 
gonorrhoea  is  treated  with  special  regard  for  its  specific  cause. 

The  intensely  contagious  quality  of  gonorrhceal  pus  has  been  too  long 
and  too  well  known  to  require  more  than  a  mention.  It  has  been  demon- 
strated b}r  direct  experiment  from  urethra  to  urethra  long  before  the  dis- 


4  VENEREAL  DISEASES. 

covery  of  the  gonococcus.  It  was  demonstrated  with  equal  certainty  by 
oculists,  by  inoculation  of  the  conjunctiva  for  clinical  purposes.  In  the 
course  of  nature  it  is  demonstrated  upon  the  victim  who  has  exposed 
himself  to  it  in  sexual  intercourse ;  and  the  eyes  of  a  patient  with  gonor- 
rhoea may  also  attest  the  powerful  contagiousness  of  this  disease. 

No  one  can  possibly  dispute  the  fact  that,  if  pus  taken  from  a  case  of 
true  gonorrhoea  be  placed  upon  the  orifice  of  the  urethra  of  the  male,  or 
the  vagina  of  the  female,  an  inflammatory  disturbance  of  considerable 
intensity  will  be  lighted  up.  But  it  was  not  until  the  discovery  of  the 
gonococcus  by  Neisser  and  its  cultivation  and  reinoculation  upon  the 
human  urethra  by  Bumm  that  the  true  etiological  factor  of  this  disease 
was  disclosed. 

On  the  other  hand,  it  is  known  that  pus  of  the  most  varied  character, 
not  gonorrhceal,  but  containing  various  forms  of  bacteria  may  be  placed 
upon  the  meatus  of  the  male  urethra,  or  poured  along  its  course,  without 
inflaming  the  canal.  In  cases  of  intense  balanitis  beneath  a  very  tight 
prepuce,  the  cavity  of  the  foreskin  is  constantly  filled  with  dense  creamy 
pus ;  yet  in  such  a  case,  if  the  foreskin  be  slit  up,  it  is  often  found  that 
the  glans  penis  is  excoriated  in  patches,  and  the  meatus  of  the  urethra 
raw  perhaps,  but  no  urethritis  exists.  Pus  from  pyelitis  may  be  voided 
as  thick  as  cream  through  the  urethra,  but  it  does  not  occasion  inflamma- 
tion of  the  canal. 

In  the  female,  pus  from  the  kidney  or  bladder,  passing  through  the 
urethra,  or  pus  in  vast  quantities  coming  from  the  uterus,  may  exert  little 
more  than  a  mild  amount  of  mechanical  irritation  upon  the  parts  over 
which  it  passes. 

Finally,  the  male  often  cohabits  with  a  female  whose  vagina  contains 
more  or  less  pus  from  the  uterus,  and  remains  well ;  while  in  many  cases 
a  man  with  a  more  or  less  purulent  discharge  may  lie  with  a  woman,  and 
she  will  remain  sound.  Not  so  in  either  case,  however,  if  there  be  pres- 
ent the  microbic  poison  of  gonorrhoea.  A  gleet  after  gonorrhoea  which  is 
nearly  well  may  give  a  gonorrhoea  to  a  woman  if  the  gonococcus  be  still 
present,  as  will  a  mild  lurking  inflammation  in  the  vagina  readily  poison 
the  male  when  its  secretion  harbors  the  presence  of  this  specific  organism. 

A  large  percentage  of  men  in  cities  have  a  small  amount  of  gleet  from 
one  cause  or  another ;  yet  gonorrhoea  in  the  females  (their  wives),  with 
whom  they  cohabit,  is  not  common— it  is,  indeed,  exceptional.  In  France 
a  gleet  is  considered  a  natural  thing  with  a  soldier,  so  much  so  that 
it  is  called  the  "  military  drop  " ;  but  the  women  with  whom  they  live  are 
not  necessarily  affected  with  an  analogous  disorder.  Indeed,  there  are 
certain  forms  of  urethral  discharge,  which,  the  gonococcus  having  been 
carefully  excluded,  may  call  for  the  married  state  for  their  cure,  and 
which  get  well  during  regular  sexual  hygiene,  without  involving  the  wife 
in  any  disorder. 


SPECIFIC   AND   NON-SPECIFIC   URETHEITIS — GONORRHCEA.  5 

As  to  the  power  of  pus  in  the  vagina  to  give  gonorrhoea  to  the  male. 
Doubtless  the  male  often  gets  his  urethritis  from  contact  with  such  irri- 
tating discharges,  but  he  does  not  necessarily  become  irritated  by  them 
at  all.  Indeed,  he  usually  escapes,  unless  his  own  urethra  has  been 
damaged  by  previous  gonorrhoea,  and  he  happens  to  be  himself  either 
debilitated,  overtired,  or  full  of  liquor,  or  suffering  coincidently  from 
very  acid  urine,  or  unless  he  overstiinulates  himself  sexually.  All  of 
these  causes  are  capable  alone  of  producing  urethritis  when  the  mucous 
membrane  is  in  a  morbid  or  congested  condition,  but  are  more  apt  to  be 
predisposing  in  their  nature,  and  the  means  of  inducing  acute  inflamma- 
tion, through  the  activity  of  the  various  micro-organisms  which  commonly 
infest  the  urethra  and  vagina,  and  which,  although  not  necessarily  patho- 
genic, may  become  so  under  certain  conditions. 

When  a  patient,  however,  offers  himself,  in  sexual  exposure,  to  the 
diplococcus  of  true  gonorrhoea,  he  is  almost  certain  to  become  poisoned 
•without  the  co-operation  of  any  of  the  adjuvants  mentioned  above.  A 
simple  exposure  is  enough. 

The  theoretical  distinction,  therefore,  between  gonorrhoea  and  urethri- 
tis is  clear;  the  clinical  distinction  is  often  equally  so.  Yet,  without 
dovbt,  an  intense  urethritis  is  one  and  the  same  in  its  symptoms,  whether 
its  cause  be  the  gonorrhoeal  virus  or  any  other  microbic  agent  internal  or 
external. 

From  what  has  been  written,  it  may  be  inferred  that  the  causes  of 
urethral  inflammation  are  quite  varied.  The  cause  of  true  virulent 
gonorrhoea  is  single,  namely,  contact  of  the  affected  person  with  gonor- 
rhoeal pus  from  another  person.  Urethritis,  however,  may  be  produced 
in  a  variety  of  ways  almost  infinite,  and  it  cannot  be  distinguished '  in 
its  symptoms,  when  intense,  from  a  gonorrhoea.  This  fact  cannot  be  too 
often  repeated.  That  surgeon  is  bold  indeed,  who,  in  the  face  of  a  cer- 
tain urethral  discharge  of  given  intensity,  without  the  use  of  the  micro- 
scope will  pronounce  upon  its  origin  with  any  confidence,  and  some  writers 
on  account  of  the  close  resemblance  in  every  particular  of  other 
micro-organisms  to  the  gonococcus  by  microscopic  examination,  deem  it 
necessary  to  resort  to  further  bacteriological  technique  with  the  purpose  of 
obtaining  a  pure  culture  in  a  suitable  medium,  before  the  question  of  its 
presence  in  a  given  discharge  can  be  satisfactorily  passed  upon  (see  Bac- 
teriology of  Urethritis).  No  one  can  be  accused  of  impure  relations  be- 
cause he  has  a  profuse  urethral  discharge.  It  cannot  even  be  said  that 
such  a  person  has  had  sexual  intercourse  at  all ;  for  it  is  possible  for  a  man, 
virgin  of  all  venery,  to  have  an  intense  urethral  inflammation,  and  much 
injustice  may  be  done  by  accusing  him,  on  the  one  hand,  or,  on  the  other, 
of  accusing  his  partner— if  he  has  had  one — of  having  given  him  a  dis- 
ease. 

The  moral  is,  that  the  physician  is  not  a  judge.     His  function,  if  he 


(J  VENEREAL  DISEASES. 

has  any  of  the  judicial  sort,  is  to  shield  the  innocent.  He  should  accuse 
no  one,  but  confine  himself  to  his  own  proper  duties. 

If  the  urethra  be  healthy,  it  does  not  easily  become  inflamed,  except- 
ing by  contact  with  gonorrhoeal  pus.  Yet  a  healthy  urethra  does  some- 
times suppurate  after  mechanical  violence,  such  as  the  rough  introduction 
of  instruments  through  it;  after  chemical  violence — the  injection  of  irri- 
tating substances  for  experiment,  or  under  the  idea  of  employing  a  pro- 
phylactic against  supposed  infection.  Under  these  circumstances  the 
micro-organisms  which  are  latent  in  the  urethra  exert  a  more  or  less 
virulent  action  against  it  as  a  result  of  the  traumatism  induced.  A 
healthy  urethra  may  also  become  inflamed  by  the  combined  influence  of 
venereal  excitement — especially  if  intense  or  prolonged — and  contact  of 
an  irritating  discharge,  leucorrhoeal  pus,  menstrual  blood,  etc.  Here  the 
virulent  factor  is  derived  from  without. 

An  unhealthy  urethra  is  always  ripe  and  ready  for  inflammation.  In 
strumous,  strongly  lymphatic,  gouty,  and  rheumatic  subjects,  the  urethra 
seems  prone  to  take  on  inflammation  easily,  especially  if  the  person  be 
cachectic,  overworked,  or  reduced  in  general  health  from  any  cause.  In 
such  cases  all  the  mucous  membranes  are  apt  to  be  in  an  irritable  condi- 
tion, and  to  take  on  subacute  inflammation  from  trivial  causes. 

When  the  urethra  is  actually  diseased,  on  account  of  the  previous 
existence  in  it  of  acute  inflammation — when  it  contains  a  thickened, 
hypersemic  patch,  constituting  a  slight  stricture — then  it  is  in  a  prime 
condition  to  be  irritated  into  suppuration — often  a  suppuration  of  formid- 
able proportions — by  the  action  of  those  micro-organisms  which,  in  the 
healthy  urethra,  fail  to  produce  any  apparent  irritation.  This  is  espe- 
cially true  when  the  urethra,  besides  being  the  seat  of  a  chronic  patch  of 
congestion  left  behind  by  an  old  gonorrhoea,  is,  at  the  same  time,  clia- 
thetically  unhealthy,  owing  to  the  broken  health,  the  bad  hygienic 
surroundings,  the  cachectic  condition,  the  nervous  prostration,  or  the 
scrofulous  or  gouty  constitution  of  the  patient. 

When  the  mucous  membrane  of  the  urethra  is  unhealthy,  the  intro- 
duction of  a  sound  will  sometimes  produce  quite  a  sharp  attack  of  ure- 
thritis.  The  passage  of  very  acid  urine  through  the  canal  may  bring 
about  the  same  result,  whether  the  uric-acid  crystals  be  due  to  indiges- 
tion, an  attack  of  gout,  or  over-stimulation  by  alcohol  (particularly  beer 
or  champagne).  Mere  excess  of  sexual  excitement  will  sometimes  pro- 
duce a  flow  of  pus,  and  prolonged  sexual  intercourse  may  do  the  same, 
particularly  if  there  be  any  purulent  discharge  in  the  vagina.  In  early 
married  life  the  male  is  not  unlikely  to  get  a  little  urethritis  from  his 
wife ;  but  after  his  approaches  become  less  amorous,  he  has  no  further 
trouble. 

In  connection  with  many  morbid  states  of  the  prostate  (cancerous, 
tuberculous,  inflammatory)  and  of  the  urethra  (herpetic,  chancrous — 


SPECIFIC   AND   NON-SPECIFIC   URETHRITIS — GONORRHCEA.  7 

tuberculous,  syphilitic)  a  more  or  less  purulent  flow  from  the  urethra  may 
be  encountered,  and  a  purulent  discharge  attendant  upon  organic  stricture 
is  of  every-day  occurrence. 

BACTERIOLOGY  OF  URETHRITIS. 

The  various  micro-organisms  which  normally  inhabit  the  anterior 
urethra  have  been  isolated  and  studied  by  different  observers,  notably 
Lustgarten  and  Mannaberg,  Stein  Schneider,  Pettit,  and  Wassermann.  The 
writings  of  these  and  other  authorities  furnish  us  with  a  knowledge  of 
the  bacterial  flora  of  the  normal  urethra.  An  enumeration  of  the  differ- 
ent forms  would  occupy  unnecessary  space.  It  is  sufficient  to  state  that 
these  comprise  bacilli  of  varying  lengths  and  contour;  cocci  variously 
grouped;  diplococci,  round,  oval,  and  hemispherical;  streptococci,  small 
and  large;  staphylococci,  round  and  oval  and  of  different  sizes.  There- 
fore when  the  gonococcus  is  implanted  upon  the  urethra  it  is  not  inocu- 
lated upon  a  sterile  territory,  but  one  where  already  thrive  myriads  of 
different  micro-organisms.  How  these  latter  modify  the  action  of  the 
gonococcus  is  hardly  known,  or  what  part  they  play  in  limiting  its  career 
in  the  urethra.  That  their  presence  is  harmless  in  the  quiescent  state 
is  beyond  dispute,  but  that  they  assume  under  certain  conditions  very 
virulent  properties  seems  to  be  proven  in  those  forms  of  urethritis  which 
come  under  the  title  of  non-specific  inflammation. 

It  is  now  generally  accepted  that  the  gonococcus  is  the  microbic  agent 
of  true  gonorrhoea.  It  is  also  known  that  there  exists  a  close  analogy 
between  some  of  the  other  diplococci  and  the  specific  organism  of  true 
gonorrhoea  (the  gonococcus  of  Neisser).  In  fact  it  is  maintained  by 
some  that  the  so-called  pseudo-gonococcus  and  the  gonococcus  of  Neisser 
are  indistinguishable  in  some  instances,  in  which  the  former  partakes 
of  the  characteristics  of  the  latter  without  variation.  Improvement  in 
bacteriological  technique,  however,  and  the  discovery  of  a  reliable  culture 
medium  for  the  gonococcus  make  its  differentiation  a  practical  certainty, 
as  it  has  been  possible  to  reinoculate  upon  the  human  subject  from  a 
pure  culture  and  demonstrate  conclusively  the  specific  action  of  the  gonor- 
rhceal  organism.  When  the  evidence  furnished  by  means  of  the  microscope 
and  cover-glass  preparations  is  negative,  resort  may  be  had  to  cultivation 
on  a  proper  medium  when  absolute  certainty  of  diagnosis  is  required. 
The  advantage  of  cultivation  is  mainly  in  those  cases  in  which  a  few  shreds 
or  filaments  are  present  in  the  urine  and  nothing  more,  and  in  the  case 
of  patients  who  suffer  from  a  very  mild  catarrhal  gleet  and  who  contem- 
plate matrimony.  In  either  o£  this  class  of  cases  a  positive  diagnosis  may 
be  desired,  but  the  gonococci,  if  present  at  all,  are  so  scarce  that  the 
microscope  may  fail  to  find  them  until  their  number  is  greatly  augmented 
by  propagation  upon  a  suitable  medium.  But  when  there  are  present  in 


8  VENEREAL  DISEASES. 

a  given  discharge  suspicious  organisms,  which  can  be  seen  with  the  mi- 
croscope to  resemble  the  gonococcus,  differentiation  can  be  satisfactorily 
made  without  cultivation,  by  means  of  the  Gram  method  of  staining 

(Plates  III.-VIL). 

In  cases  of  non-specific  urethritis  and  pseudo-gonorrhceal  inflammation 
examination  of  the  discharge  reveals  the  presence  of  different  kinds  of 
bacteria,  such  forms  as  cocci  and  bacilli,  which  are  known  to  be  present 
in  normal  vaginal  and  urethral  secretions.  That  these  organisms  enter 
somewhat  into  the  causative  agency  of  non-specific  inflammation  there  is 
no  doubt,  but  in  this  particular  they  differ  materially  from  the  gonococ- 
cus, that  their  separation  in  pure  culture  and  reinoculation  do  not  result 
in  the  production  of  a  similar  inflammation,  and  therefore  they  may  be 
said  to  be  only  one  of  the  factors  which  enter  into  the  causation  of  non- 
specific urethritis. 

Bockhart,1  in  examining  cases  of  catarrhal  urethritis,  found  present  in 
large  numbers  specimens  of  bacteria  which  inhabit  the  normal  vaginal 
secretion.  Bacilli  were  found  only  in  small  numbers.  As  the  process  of 
inflammation  advanced,  the  number  of  organisms  diminished  so  that 
finally  one  form  only  remained — a  micrococcus.  He  found  a  coccus  like 
the  staphylococcus  grouped  as  diplococci.  These  were  smaller  than  the 
gonococci,  the  segments  being  hardly  as  large  as  the  erysipelas  cocci. 
No  concavity  in  the  segment  was  observed.  They  were  isolated  or  in 
clusters  of  great  colonies.  They  were  found  within  epithelial  cells  as 
well  as  within  the  protoplasm  of  the  pus  cells. 

Krause  and  Hirschberg,  in  examining  several  hundred  ocular  secre- 
tions, frequently  found  micro-organisms  closely  resembling  the  gonococcus 
Neisser,  which  were  hard  to  differentiate  from  the  latter. 

Elkhund  found  a  similar  form  of  diplococcus  in  the  secretions  of 
acute  and  chronic  suppurative  processes  of  the  lungs  and  intestines  and 
in  ulcerous  stomatitis. 

Bumm  with  Bockhart  discovered  organisms  closely  resembling  the 
gonococcus  in  the  genital  tract  of  women.  The  former  observer  in  ex- 
tensive investigations  has  made  a  study  of  the  various  organisms  which 
closely  resemble  the  gonococcus  in  the  minutest  detail.  Some  of  these 
are  pathogenic  and  others  not.  He  enumerates  several  of  the  spurious 
forms  and  gives  their  bacteriological  characteristics.  The  principal  ones 
are :  1.  A  lemon-yellow  diplococcus,  non-pathogenic,  found  in  the  dust  of 
the  air,  also  in  purulent  secretions  of  the  urethra  and  conjunctiva.  2. 
A  milk-white  diplococcus,  non-pathogenic,  found  in  the  preputial  smegma 
and  in  various  secretions  of  the  body  and  in  ulcerous  processes  of  the 
vagina  and  mouth.  3.  A  yellowish-white  diplococcus,  pathogenic,  found 
in  the  lochial  discharges,  in  the  catarrhal  urine  of  women  after  childbirth, 
also  in  mammary  abscesses.  4.  A  gray -white  diplococcus,  non -pathogenic, 

1  Monatschrift  fur  Derm.,  1886,  p.  134. 


KEYES   AND  CHETWOOD. 


PLATE   I. 


1.  Colony  on  nutrient  agar  of  large  dlplococcus  from  normal  urethra.    Magnified. 

2.  Microscopical  examination  of  same  organism.    1,000  diameters. 

3.  Pure  culture  on  acid  gelatin  of  Turro's  diplococcus  urethrae.    1,000  diameters. 

4.  Colony  on  nutrient  agar  plate  of  diplococcus  found  in  catarrhal  colpitis.    Magnified. 

5.  Microscopical  examination  of  same  organism.    1,000  diameters. 

CULTURES  OF  DIPLOCOCCI  SOMETIMES   MISTAKEN   FOR  THE  GONOCOCCUS.     (HEIMAN.) 


SPECIFIC  AND   NON-SPECIFIC   URETHRITIS — GONORRHOEA.  9 

found  in  vaginal  secretions.  5.  A  red  diplococcus  found  in  the  dust  of 
the  air,  non-pathogenic.  Most  of  the  above  organisms  are  found  to  be 
readily  cultivated  at  ordinary  temperatures. 

It  seems  possible  to  cultivate  them  on  gelatin  and  other  ordinary 
media  without  difficulty,  differentiating  them  from  the  gonococcus,  which 
is  difficult  to  cultivate  and  requires  a  special  medium  (Plates  I.  and  II.). 

Xeisser1  declares  that  urethritis  can  be  caused  by  other  bacteria  than 
the  gonococcus.  He  mentions  a  case  in  which  no  gonococci  were  found, 
but  a  large  number  of  intra-  and  intercellular  "  bacilli  diplococci "  ("  Stab- 
chen  diplococci ")  were  present. 

The  Gonococcus. — The  gonococcus  was  discovered  by  Neisser  in  1879 
in  gonorrhceal  pus,  and  was  first  cultivated  by  Bumm  in  1885.  These 
organisms  consist  morphologically  of  micrococci,  usually  joined  in  pairs 
(diplococci)  or  in  groups  of  four.  The  separate  elements  are  flattened  or 
hemispherical  with  the  flattened  surfaces  approximated,  and  in  the  stained 
preparation  presenting  an  unstained  interspace.  The  approximated  faces 
sometimes  present  a  slight  concavity.  Their  average  size  is  1.25  p.  in 
the  long  diameter.  Their  multiplication  occurs  by  fission,  alternately  in 
two  planes,  as  a  result  of  which  groups  of  four  are  frequently  observed. 
The  diplococci  are  more  frequent.  Single  spherical  individual  cells  are 
rarely  seen.  The  microscopical  appearances  are  not  entirely  characteristic 
of  the  gonococcus,  as  various  other  diplococci  cannot  be  distinguished 
morphologically  from  the  gonococcus.  It  readily  stains  with  the  basic 
aniline  colors,  especially  with  methyl  violet,  gentian  violet,  and  fuchsin. 
It  is  negative  to  Gram's  stain — that  is  to  say,  it  is  decolorized  by  the 
iodine  solution  used  in  this  method.  It  has  been  stated  that  this  char- 
acteristic does  not  serve  to  differentiate  it,  as  other  diplococci  have  been  . 
found  in  gonorrhceal  pus  which  react  in  the  same  way  (Bumm);  but 
it  is  held  on  equally  good  authority  that  the  characteristic  action  of 
the  Gram  method  upon  the  gonococcus  is  the  best  and  most  reliable 
means  of  establishing  its  identity,  and  that  when  confounded  with  other 
diplococci  the  error  is  due  to  faulty  technique.  In  our  judgment  there 
is  no  better  means  than  the  Gram  test  for  recognizing  the  gonococcus, 
but  the  greatest  pains  must  be  taken  in  every  detail  to  make  this  test 
conclusive. 

Another  distinguishing  characteristic  but  of  lesser  diagnostic  value  is 
the  fact  that  the  diplococcus  gonorrhosae  is  found  within  the  protoplasm  of 
the  pus  cells.  It  is  found  also  within  the  epithelial  cells.  Pus  cells  are 
observed  entirely  filled  with  these  organisms.  Bumm  describes  what  he 
considers  the  one  exception  in  a  diplococcus  found  within  pus  cells  from 
a  case  of  puerperal  cystitis.  These  cocci  retained  their  color  after  being 
treated  by  the  Gram  method  of  staining. 

1  Deutsche  med.  Wochenschrift,  1893. 


10  VENEREAL,  DISEASES. 

To  fix  the  identification,  then,  of  the  gonococcus  there  should  be  diplo- 
cocci  of  tha  right  form,  size,  and  arrangement.  They  must  be  negative 
to  Gram  staining,  and  should  be  observed  -within  the  protoplasm  of  the 
pus  cells.  The  method  of  establishing  the  identity  of  the  gonococcus 
by  more  elaborate  bacteriological  technique— namely,  its  cultivation  upon 
a  proper  medium,  also  demands  recourse  to  the  Gram  staining  as  a  final 
means  of  identification. 

The  gonococcus  does  not  grow  upon  the  ordinary  cultivating  media. 
It  thrives  best  at  the  body  temperature.  The  extreme  degrees  of  temper- 
ature in  which  it  grows  are  between  25°  and  39°  C. 

Various  special  media  have  been  used  successfully  in  the  cultivation 
of  this  organism.  Hammer1  describes  a  mixture  of  albuminous  urine 
containing  1  to  1.5  per  cent  albumin  with  glycerin  agar.  The  two  con- 
stituents are  separately  sterilized  and  then  mixed.  Upon  this  medium 
the  author  obtained  rich  growths  of  the  organism. 

Burma  first  succeeded  in  cultivating  the  gonococcus  upon  human  blood 
serum  prepared  from  the  placenta  of  a  recently  delivered  woman.  The 
other  media  used  successfully  have  been  prepared  by  mixing  two  parts 
of  glycerin  agar  with  one  part  of  fluids  rich  in  albumin,  such  as  ascitic 
fluid,  fluid  from  hydrothorax,  hydrocele,  or  ovarian  cysts.  A  more  sim- 
ple plan  is  the  use  of  the  ordinary  nutrient  agar,  the  surface  of  which 
has  been  richly  spread  with  human  blood.  The  blood  may  be  obtained 
directly  from  a  small  cut.2 

The  gonococcus  is  a  facultative  anaerobe.  Cultures  upon  the  surface 
of  blood  serum  are  thin  and  scarcely  visible.  The  surface  is  smooth, 
moist,  and  shining,  yellow  by  reflected  light;  the  edges  of  colonies  are 
finely  serrated.  The  growth  spreads  but  slightly  and  does  not  continue 
more  thau  two  or  three  days,  as  the  cocci  lose  their  vitality.  It  is  a 
strict  parasite.  (Sternberg.) 

Unless  dried  out,  the  gonococci  may  retain  their  vitality  upon  serum 
agar  at  the  body  temperature  for  four  weeks.  If  dried  they  lose  their 
vitality  within  a  few  hours. 3 

The  gonococcus  has  never  been  found  outside  of  the  body  as  a  harm- 
less saprophyte.  According  to  Heiman4  the  gonococcus  remaining  in  the 
urethra  after  a  gonorrhoea  may  lie  dormant  there  and  remain  innocuous 
for  years,  and  yet  at  any  time  excite  an  acute  gonorrhoea  in  another  per- 
son ;  but  this  same  author  believes6  that  the  statements  of  Strauss,  Pes- 
cioni,  and  Eraud,  that  the  gonococcus  occurs  as  a  denizen  of  the  normal 
urethra,  are  not  satisfactorily  proven  by  their  published  experiments. 

1  Deutsche  med.  Woch.,  1895,  p.  GO. 

'Abel:  Deutsche  med.  Woch.,  1893,  p.  265.  Fischer:  Berliner  kl  in.  Woch., 
1895,  p.  1156. 

3  Lehmann:  "Bak.  Diag.,"  1896,  p.  151. 

4  Medical  Record,  December  19, 1896.  <•  Ibid. 


KEYES   AND  CHETWOOD. 


PLATE    II. 


V-  5V  -% 
^\ 


1.  Colony  on  chest-serum  agar  of  gonococci  from  male  urethra.    Magnified. 

2.  Microscopical  examination  of  a  pure  culture.    1,000  diameters. 

3.  Gonorrhoeal  pus  sown  on  chest-serum  agar,  showing  a  pure  gonococcus  culture. 


CULTURES  OF  THE  GONOCOCCUS.  (HEIMAN.) 


SPECIFIC   AND   NON-SPECIFIC   URETHRITIS — GONORRHOEA.         11 

The  various  localities  in  which  the  gonococcus  has  been  found  comprise 
the  urethra  and  prostate  of  man,  the  urethra,  Bartholin's  glands,  and  the 
cervix  uteri  of  women.  It  has  been  found  as  the  cause  of  vaginitis  and 
urethritis  of  young  girls.  It  has  been  discovered  in  endometritis,  urethri- 
tis,  salpingitis,  oophoritis,  peritonitis,  proctitis ;  probably  also  in  epididy- 
mitis  and  cystitis;  also  in  blennorrhoea  neonatorum,  conjunctivitis, 
rhinitis,  otitis,  and  arthritis.  It  is  still  uncertain  whether  it  occurs  as 
the  cause  of  pleuritis  and  malignant  endocarditis. 

Flattened  epithelial  cells  seem  to  serve  as  a  better  protection  against 
infection  than  do  columnar  epithelia. 

This  parasite  has  been  observed  to  have  penetrated  the  epithelium,  and 
to  have  reached  the  connective  tissue  beneath. 

Immunity  does  not  follow  infection. 

Attempts  to  inoculate  the  lower  animals  are  not  successful  and  do  not 
produce  the  true  gonococcus  of  Neisser,  but  may  yield  a  spurious  organ- 
ism, somewhat  resembling  it  morphologically,  but  which  can  be  differ- 
entiated from  it  by  means  of  the  Gram  test  properly  conducted. 

In  order  to  demonstrate  the  presence  of  the  gonococcus  in  cover-glass 
preparations  we  believe  that  the  method  of  Gram  should  be  relied  upon 
entirely,  and  therefore  a  clear  understanding  of  the  various  steps  included 
in  this  staining  method  and  differential  test  is  absolutely  necessary  to 
success. 

In  a  valuable  communication  of  his  work  in  the  library  of  the  Paris 
Necker  Hospital  Dr.  M.  Weinrich,  of  Berlin, '  lays  great  stress  upon  what 
he  considers  the  most  fruitful  source  of  error  in  the  conduct  of  this  test, 
namely,  the  use  of  water  for  washing  purposes  in  any  of  the  steps.  He 
believes  that  by  so  doing  complete  decoloration  of  the  gonococcus,  when 
washed  in  alcohol,  is  interfered  with. 

/  What  is  known  as  Gram's  solution  consists  of  the  following  combina- 
tion :  Iodine  1  part,  iodide  of  potassium  2  parts,  water  300  parts.  This 
preparation  is  used  in  bacteriological  technique  for  demonstrating  the 
presence  of  various  bacteria.  The  specimen  is  previously  stained  for  one  or 
two  minutes  by  a  solution  of  gentian  or  methyl  violet,  when  it  is  treated  by 
the  Gram  solution  for  the  same  length  of  time.  This  solution  in  the 
presence  of  the  aniline  dye  forms  an  insoluble  deposit  which  is  confined 
to  the  bacteria,  and  which  in  the  case  of  most  bacteria  is  not  dissolved 
out  when  treated  with  absolute  alcohol  until  the  specimen  appears  color- 
less to  the  naked  eye.  In  treating  the  gonococcus  of  Neisser,  however, 
in  the  same  manner  as  above,  it  was  discovered  that  the  Gram  stain  is 
dissolved  out  of  these  organisms  by  the  alcohol,  while  it  remains  fixed 
in  any  other  organisms  which  may  be  present  in  the  same  field.  Thus 
it  may  be  seen  that  we  have  here  a  most  valuable  differential  test  for  the 

!  Annal.  des  Malad.  des  Organ.  Genito-Urin.,  May,  1898. 


12  VENEREAL,   DISEASES. 

gonococcus.  As  a  final  means  of  detecting  gouococci,  after  they  have 
been  subjected  to  the  various  steps  of  the  Gram  process,  it  is  necessary  to 
submit  them  to  a  restaining  by  another  aniline  dye,  preferably  one  which 
is  markedly  different  in  color  from  the  original  stain  used  in  the  Gram  test? 
In  the  final  microscopic  examination  of  the  dischargefrom  a  case  of  gon- 
orrhoea we  have  in  the  field  a  number  of  organisms  which  are  not  gono- 
cocci  colored  by  the  Gram  stain,  and  in  contrast  to  these  the  gonococci 
with  the  color  of  the  second  dye  or  counter-stain  (Plates  VI.  and  VII.). 

Thin  smears  of  pus  are  first  prepared  on  cover  glasses  and  allowed  to 
dry  in  the  air  spontaneously,  or  artificially  by  means  of  very  gentle  heat. 
The  smear  is  then  "  fixed  "  by  passing  the  cover  glass  three  times  through 
the  flame  of  an  alcohol  lamp  or  Bunsen  burner.  The  first  step  in  the 
Gram  method  is  to  stain  the  smear  with  a  solution  of  aniline  dye.  One 
of  the  best  is  that  known  as  Ehrlich's  solution,  composed  of  a  saturated 
alcoholic  solution  of  gentian  violet,  10  parts,  in  90  parts  of  aniline  water 
(Hogge).  Aniline  water  is  prepared  by  emulsifying  1  part  of  aniline  oil 
in  20  parts  of  distilled  water  by  shaking  in  a  test  tube.  Allow  the 
emulsion  to  stand  a  moment  and  filter  through  a  wet  filter  until  the  fil- 
trate is  perfectly  clear.  Now  cover  the  smear  with  the  above  aniline 
gentian-violet  solution,  and  allow  it  to  stain  for  one  or  two  minutes.  Do 
not  wash  with  water,  but  remove  the  surplus  dye  by  means  of  filter  paper 
and  transfer  immediately  to  the  Gram  solution,  where  it  should  also  re- 
main for  one  or  two  minutes.  Next,  again  without  washing  with  water, 
immerse  in  absolute  alcohol  until  the  color  disappears  and  the  preparation 
is  perfectly  clear  to  the  naked  eye.  This  should  take  from  one  minute  to 
two  minutes  when  the  previous  steps  have  been  properly  conducted. 
If  water  be  used  between  the  stages,  or  if  the  alcohol  be  not  absolute, 
the  process  of  decoloration  will  take  much  longer  and  the  ultimate  result 
may  be  unsuccessful.  After  this  stage  of  decoloration  by  means  of 
the  absolute  alcohol  the  gonococci  will  have  lost  their  stain,  while  many 
other  forms  of  cocci,  such  as  staphylococci,  which  may  be  present  in  the 
pus,  will  still  retain  the  dye  (Plate  V.).  It  now  becomes  necessary  to 
counterstain  the  gonoccocci  with  some  other  color,  and  for  this  purpose  we 
employ  either  Bismarck  brown  or  Victoria  blue.  The  Bismarck  brown 
is  prepared  by  adding  3  parts  of  the  brown  to  70  parts  of  distilled  water 
and  30  parts  of  alcohol.  The  Victoria  blue  solution  is  made  by  adding  1 
part  of  the  saturated  alcoholic  solution  of  this  dye  to  100  parts  of  water. 
The  smear  is  treated  with  one  of  the  above  solutions  for  about  three 
minutes,  after  which  it  may  be  washed  with  water.  The  specimen  may 
also  be  washed  with  water  after  it  has  been  decolorized  with  alcohol  and 
•efore  the  counter-stain  is  used,  the  Gram  process  being  then  complete. 
Anally  the  preparation  is  dried,  mounted  in  Canada  balsam  upon  a  slide 
with  the  smear  turned  downward,  and  examined  with  a  Tyinch  oil-im- 
mersion objective  (Plates  VI.  and  VII.). 


KEYES   AND   CHETWOOD. 


PLATE    III. 


Specimen  taken  from  case  of  Gonorrhoeal  Urethritis,  stained  with  gentian  violet  solution. 
Here  the  gonococci  and  pseudo-gonococci  are  stained  alike  and  cannot  be  clearly  differentiated.  2,000 
diameters. 


KEYES  AND   CHETWOOD. 


PLATE   IV. 


Specimen  from  same  case  of  Gonorrhoeal  TJrethrltis  as  Plate  III.,  treated  by  the  Gram  method,  but 
before  restaining.  Here  the  gonococci  which  do  not  take  the  Gram  stain  are  decolorized  by  the  ab- 
solute alcohol,  while  the  pseudo-forms,  in  marked  contrast,  retain  the  Gram  color.  2,000  diameters. 


KEYES  AND  CHETWOOD. 


PLATE  V. 


« 


Specimen  trom  same  case  of  Gonorrhoeal  Urethritls  as  Plate  HI.,  treated  by  the  Gram  method, 
and  restained  with  Victoria  blue.  Here  the  gonococci  take  the  color  ot  .the  secondary  stain,  while 
the  pseudo-forms  retain  the  Gram  color.  2,000  diameters. 


KEYES   AND  CHETWOOD. 


PLATE    VI. 


Specimen  from  the  same  case  and  treated  in  the  same  manner  as  Plate  V.,  but  restained  with  Bis- 
marck brown.    2,000  diameters. 


KEYES   AND   CHETWOOD. 


PLATE    VII. 


o 


0 


II 


V 


Specimen  from  case  of  Non-Specific  TTrethritis,  showing  pseudo-gonococci  stained  with  gentian 
violet.    2,000  diameters. 


SPECIFIC    AND   NON-SPECIFIC    URETHRITIS — GONORRHCEA. .        13 

i 

i.  Fraenkel,  of  Hamburg, '  has  suggested  the  substitution  of  carbolated 
for  aniline  water  in  the  preparation  of  Ehrlich's  solution  and  in  the  same 
proportion,  that  is  to  say,  10  parts  of  saturated  alcoholic  solution  of 
gentian  violet  to  90  parts  of  two-per-cent  carbolated  water,  and  this 
author  has  found  that  the  above  solution  resists  decomposition  for  a 
much  longer  period  than  the  aniline-water  preparation,  and  on  this  ac- 
count it  is  certainly  to  be  recommended  as  a  desirable  substitute,  for  any 
decomposition  in  the  aniline  gentian-violet  solution  is  liable  to  lead  to 
errors  in  the  microscopical  examination,  in  view  of  which  possibility  it  has 
been  recommended  that  the  aniline  solution  be  made  fresh  before  each 
examination.  By  using  the  carbolated  solution  this  precaution  becomes 
unnecessary. 

|  To  recapitulate,  the  steps  in  staining  cover-glass  preparations  in  ex- 
amining for  the  gonococcus  are:  First  spread  a  very  fine  film  of  dis- 
charge upon  a  cover  glass.  Allow  this  to  dry  spontaneously  or  by  gentle 
heat.  "  Fix  "  by  passing  the  cover  glass  three  times  through  the  flame 
of  an  alcohol  or  Bunsen  burner.  Stain  with  gentian-violet  solution,  pre- 
ferably that  made  with  carbolated  water,  for  a  period  of  one  or  two  minutes. 
Remove  the  surplus  solution  with  filter  paper,  but  do  not  wash  with 
water.  Next  immerse  in  the  Gram  solution  for  a  similar  period.  De- 
colorize with  absolute  alcohol  until  the  specimen  is  clear  to  the  nailed 
eye.  This  should  take  about  one  minute  and  a  half.  Now  wash  in 
water  [the  Gram  test  being  completed]  to  remove  the  alcohol  and  restain 
with  a  solution  of  Bismarck  brown  or  Victoria  blue.  Wash  again  in 
water,  dry  the  cover  glass,  and  mount  with  Canada  balsam.  Examine 
with  -J^-inch  oil-immersion  objective. 

In  keeping  with  the  careful  observations  of  Nogues,  Weinrich,  and 
others,  we  must  emphasize  the  most  important  precaution  in  the  conduct 
of  this  process  to  insure  a  successful  result — namely,  the  use  of  absolute 
alcohol  for  the  purpose  of  decoloration  and  the  avoidance  of  the  use  of 
water  between  the  various  steps,  until  after  decolorization  shall  have 
been  effected. 

SYMPTOMS  OF  UBETHRITIS. 

In  studying  the  symptoms  of  inflammation  of  the  urethra,  it  will  be 
convenient  and  practical  to  make  two  classes  of  cases,  according  to  the  in- 
tensity of  the  inflammation,  and  briefly  to  review  the  symptoms  in  each. 

Symptoms  of  Simple  Non-Specific  TJrethritis. — This  is  by  far  the  com- 
monest form  of  urethritis.  This  is  likely  to  be  the  form  which  those  have 
who  boast  of  a  dozen  or  more  attacks  of  gonorrhoea,  and  of  those  indi- 
viduals who  claim  they  get  the  gonorrhoea  constantly,  but  do  not  mind 
it,  as  they  have  a  little  injection  which  cures  it  up  in  three  or  four 

1  Deutsche  med.  Wochenschrift,  1885. 


14  VENEREAL  DISEASES. 

days.  In  this  form  the  patient  gives  himself  the  disease  much  more  than 
his  partner  gives  it  to  him.  He  has  a  damaged  patch  of  mucous  mem- 
brane within  his  urethra,  and  any  on!  of  a  number  of  exciting  causes  is 
sufficient  to  kindle  the  slumbering  congestion  into  an  active  discharging 
inflammation  with  the  aid  of  those  micro-organisms  which  constantly  in- 
habit the  urethra  and  vagina,  and  under  normal  conditions  remain  there 
as  harmless  saprophytes. 

In  these  cases  the  discharge  may  originate  at  a  certain  distance  within 
the  urethra  from  the  very  start.  It  may  not  commence  at  the  meatus. 
The  patient  has  intercourse  perhaps  with  a  woman  who  has  no  gonor- 
rhoea— who  at  most  has  a  purulent  leucorrhcea.  In  twenty -four  to  forty- 
eight  hours  he  presents  himself  to  the  physician  for  inspection,  stating 
that  he  has  an  attack  of  gonorrhoea. 

When  inspection  shows  that  the  lips  of  the  meatus  urinarius  are  not 
swollen,  the  attack  has  manifestly  not  begun  at  the  meatus.  When,  how- 
ever, the  cause  is  some  irritating  discharge  from  without,  not  gonor- 
rhoeal,  commonly  the  evidences  of  commencing  irritation  appear  at  the 
meatus.  The  discharge  may  be  thick  and  purulent  from  its  very  start. 
There  may  be  little  or  no  itching,  or  tingling,  along  the  course  of  the 
urethra.  There  is  some  heat  and  smarting  in  the  urethra  during  the 
urinary  act,  but  very  little  discomfort  between  times. 

A  discharge  starting  in  this  way  is  not  apt  to  be  a  true  gonorrhoea ; 
but  it  may  go  on  and  assume  all  the  quality  of  the  most  intense  gonor- 
rhoeal  urethritis,  accompanied  by  any  of  the  complications  of  gonorrhoea, 
and  absolutely  indistinguishable  from  it  clinically;  or  it  may  subside 
in  a  few  days,  or,  at  most,  weeks,  under  moderate  symptomatic  treat- 
ment, and  give  very  little  discomfort.  The  latter  termination  is  by  far 
the  more  common. 

Symptoms  of  Specific  and  Intense  Non-Specific  Urethritis. — Specific 
urethritis  always  commences  at  the  meatus,  inoculation  with  gonorrhceal 
pus  is  the  cause,  and  there  is  always  a  period  of  incubation  between  the 
moment  of  exposure  and  the  outbreak  of  the  first  symptom.  This  incu- 
bation period  is  usually  from  five  to  eight  days,  and  sometimes  much 
longer.  When,  however,  the  cause  is  not  gonorrhoeal,  the  evidences  of 
irritation  appear  almost  simultaneously  with  the  cause  or  on  the  second 
day  following;  sometimes  they  are  delayed  up  to  the  fourth  or  even 
sixth  day,  but  rarely  any  longer. 

The  first  symptom  in  these  cases  is  an  oedema  of  the  meatus,  which 
makes  the  lips  of  the  urethral  orifice  pout.  This  swelling  may  be  insig- 
nificant in  non-specific  urethritis;  it  is  invariable  in  gonorrhoea.  The 
color  of  the  orifice  of  the  urethra  is  pink  rather  than  blue.  The  patient 
feels  a  sensation  as  though  a  hair  had  been  caught  in  the  meatus  and  was 
being  drawn  through  it.  There  is  a  sensation,  varying  between  a  tick- 
ling and  an  itching,  which  is  quite  apt  to  be  complained  of,  either  at  the 


SPECIFIC   AND  NON-SPECIFIC   URETHRITIS — GONORRHOEA.         15 

very  meatus  or  at  a  point  about  three-quarters  of  an  inch  within  the 
urethra,  upon  its  under  side.  These  sensations  keep  the  patient's  mind 
fixed  upon  his  genitals,  and  call  upon  him  to  empty  his  bladder  rather 
more  frequently  than  usual.  The  passage  of  urine  over  the  tender  ends 
of  the  urethra  causes  a  hot,  stinging  pain,  an  ardor  urince,  more  or  less 
intense,  in  different  patients. 

Between  the  lips  of  the  pouting  meatus,  perhaps  faintly  sealed  with 
dried  mucus,  a  drop  of  watery  pus  is  seen  during  the  first  twenty-four 
hours.  On  the  second  day  this  drop  becomes  more  purulent,  and  all  the 
disagreeable  sensations  increase,  while  from  day  to  day  the  discharge  be- 
comes more  copious  and  more  purulent,  except  when  under  the  influence 
of  restraining  treatment. 

During  the  second  week  the  pus  from  the  urethra  assumes  a  green 
tmt,  due  to  slight  admixture  with  blood,  and  all  the  symptoms  intensify, 
unless  the  discharge  turns  out  to  be  a  mild  urethritis,  in  which  case  it 
sometimes  reaches  its  height  during  the  first  week,  and  commences  to 
decline  during  the  second.  This  it  never  does  if  it  is  true  gonorrhoea, 
and  is  allowed  to  run  unchecked. 

If  the  inflammation  runs  high  at  any  period  of  the  disease,  erections 
become  painful ;  the  inflammation  does  not  remain  confined  to  the  surface 
of  the  urethral  membrane,  but  works  down  through/  the  minute  ducts  into 
the  mucous  glands  of  the  urethra,  and  spreads  from  thence  to  the  delicate 
meshes  of  the  spongy  tissue  of  which  the  corpus  spongiosum  is  composed. 
These  meshes  of  tissue,  becoming  stiffened  and  agglutinated  together  by 
the  inflammatory  process  over  a  given  (usually  limited)  area,  no  longer 
allow  themselves  to  become  distended  by  the  influx  of  blood  which  occurs 
during  erection.  As  a  consequence,  when  the  rest  of  the  penis  is  dis- 
tended with  blood,  and  only  a  limited  portion  remains  empty,  the  empty 
part,  being  relatively  too  short,  draws  together  the  distended  parts,  act- 
ing like  a  cord  to  a  bow,  and  the  penis  becomes  curved,  its  point  of 
greatest  concavity  corresponding  to  the  inflamed  area  of  the  corpus 
spongiosum.  The  inflammation  often  does  not  run  so  high  as  to  obliter- 
ate the  meshes  of  the  corpus  spongiosum,  but  renders  them  sensitive 
when  dragged  upon.  In  such  a  case  there  will  be  a  painfi>l,  perhaps 
hard  spot  in  the  urethra  upon  erection,  but  no  bending  of  the  penis. 

This  bending  of  the  penis  is  called  chordee.  Painful  erections  are 
not  uncommon  during  the  third  week  of  a  gonorrhoea,  and  may  continue 
until  the  discharge  has  ceased.  These  intense  symptoms,  notable  in 
gonorrhoea,  are  dependent  upon  the  pathogenic  action  of  the  gonococcus 
upon  the  tissues.  This  microbic  agent  is  first  implanted  upon  the  epi- 
thelium of  the  meatus,  where  it  rapidly  proliferates  and  thence  penetrates 
gradually  between  the  cells  into  the  subepithelial  tissue.  Here  a  high 
degree  of  irritation  is  set  up  around  the  blood-vessels,  and  all  the  phe- 
nomena of  inflammation  ensue.  This  entails  desquamation,  serous  exu- 


16  VENEREAL   DISEASES. 

dation,  migration  of  large  numbers  of  white  blood  corpuscles,  and  general 
round-cell  infiltration. 

The  intensity  of  the  inflammation,  and  hence  the  symptoms  produced, 
vary  according  to  the  number  of  gonococci,  the  rapidity  with  which  they 
proliferate,  and  the  susceptibility  of  the  tissues. 

During  the  second  or  third  week,  as  the  inflammation  extends  back- 
ward within  the  canal  of  the  urethra,  the  deep  urethral  muscles  are  apt 
to  be  thrown  into  spasm,  which  leads  to  dribbling  of  urine  and  difficulty 
in  voiding  the  contents  of  the  bladder.  Sometimes  actual  retention 
comes  on,  usually  only  in  connection  with  active  inflammatory  congestion 
of  the  prostate  and  cystitis  of  the  neck  of  the  bladder.  Abscess  of  the 
prostate,  peri-urethral  abscess,  perineal  suppuration,  inguinal  glandular 
abscess,  and  swelled  testicle  are  among  the  complications  of  intense  in- 
flammation .of  the  urethra.  Inflammatory  complications  of  the  fundus  of 
the  bladder  and  of  the  kidneys  occur,  but  are  rare  in  connection  with 
gonorrhoea  unless  neglected  or  ill-treated. 

In  some  cases  the  prepuce  becomes  implicated  in  inflammation.  This 
is  due  to  a  lymphangitis,  generally  of  the  smaller  lymphatic  vessels. 
As  a  result  the  foreskin  may  swell  enormously,  and  become  white  with 
oedema,  and  this  oedema  may  go  on.  to  involve  the  whole  penis.  It  fre- 
quently leads  to  paraphimosis,  when  the  prepuce  is  short.  If  the  pre- 
puce be  long,  phimosis  is  apt  to  occur,  and  occasionally  the  inflammation 
runs  on  to  the  extent  of  producing  abscess  between  the  layers  of  the 
prepuce. 

When  the  prepuce  is  tight,  although  it  may  not  become  inflamed  in 
its  own  texture,  yet  if  the  discharge  is  not  kept  carefully  washed  out 
of  its  cavity,  the  pus  is  liable  to  be  retained  in  the  furrow  behind  the 
glans  penis,  and  there  becoming  decomposed,  to  give  rise  to  balanitis  and 
posthitis,  and  to  lead  to  the  formation  of  innumerable  warts,  the  so- 
called  venereal  warts,  which  are  always  likely  .to  be  produced  by  unclean- 
ness  beneath  the  prepuce.  The  above  evidences  of  extension  of  inflam- 
mation beyond  and  exterior  to  the  mucous  membrane  are  caused  not  by 
the  gonococcus  but  by  the  ordinary  pyogenic  micro-organisms. 

When  the  urethral  inflammation  runs  high,  hemorrhage  from  the 
urethra  may  occur,  either  spontaneously  during  erection  or  as  a  result  of 
straightening  the  curved  penis  during  erection.  When  the  penis  is  so 
straightened  the  inflamed  spot  of  corpus  spongiosum  may  be  ruptured 
through  the  mucous  membrane  of  the  urethra,  and  violent  hemorrhage 
may  folkpw,  to  say  nothing  of  the  traumatic  stricture  which  is  sure  to 
appear  subsequently  at  the  point  of  rupture. 

In  those  rare  cases  in  which  upward  chordee  appears  on  account  of 
inflammation  of  the  corpus  cavernosum,  violent  straightening  may  cause 
effusion  of  blood  within  the  sheaths  of  the  corpora  cavernosa,  but  rarely 
produces  free  bleeding  from  the  urethral  surface. 


SPECIFIC  AND  NON-SPECIFIC  URETHRITIS — GONORRHOEA.         17 

After  the  urethral  flow  has  continued  at  its  height  for  a  period  varying 
from  one  week  to  a  number  of  weeks,  the  inflammatory  symptoms  gradually 
subside,  chordee  becomes  less  frequent  and  less  intense  at  night,  the  dis- 
charge lessens,  and  finally  ceases  entirely.  It  may  relapse,  leading  to  a 
new  discharge  lasting  for  several  weeks,  or  prolong  itself  indefinitely  in 
the  shape  of  a  gleet,  which  is  more  or  less  puriform  in  different  cases, 
and  subject  to  exacerbation  and  improvement,  from  time  to  time,  from 
varied  trivial  causes. 


DIAGNOSIS,  DUKATION,  AND  TKEATMENT. 

Before  deciding  upon  the  proper  course  of  treatment  in  a  given  case 
of  urethritis,  the  determination  of  the  cause  upon  which  it  depends  is  a 
necessary  preliminary  step. 

In  the  light  of  our  present  knowledge  regarding  the  causative  agency 
of  the  gonococcus  in  cases  of  specific  urethritis,  it  is  hardly  necessary  to 
state  that  it  is  always  proper  to  resort  to  the  means  already  dwelt  upon 
to  determine  the  question  of  its  presence  in  a  purulent  discharge  from  the 
urethra. 

The  treatment  of  a  mild  case  of  non-specific  urethritis  often  resolves 
itself  into  a  simple  removal  of  the  cause  underlying  it. 

The  treatment  of  specific  urethritis  and  of  the  more  intense  form  of 
non-specific  urethritis  requires  a  resort  to  active  local  and  antiseptic 
measures,  to  be  hereinafter  described.  It  is  often  possible  to  reach  a  fair 
presumption  regarding  the  character  of  a  case  of  urethritis  by  plying  the 
patient  with  such  questions  as  will  bring  to  light  the  period  of  incubation, 
if  any,  the  intensity  of  the  symptoms,  the  number  and  duration  of  pre- 
vious attacks,  and  by  taking  account  of  the  apparent  health  and  habits 
of  the  individual.  A  patient  who  has  had  a  number  of  previous  attacks 
of  mild  urethritis,  which  have  always  yielded  to  simple  measures,  is  apt 
to  treat  the  whole  question  of  gonorrhoea  with  small  concern  and  to  en- 
deavor to  impress  his  views  upon  his  less  experienced  brethren.  Such  a 
man  has  rarely  had  more  than  one  case  of  true  gonorrhrea,  the  successive 
outbreaks  being  relapses  of  the  original  malady,  or  the  result  of  morbid 
conditions,  local  or  constitutional,  which  render  him  susceptible  to  irri- 
tating influences  which  do  not  act  upon  the  normal  urethra.  A  first 
attack  of  acute  urethral  inflammation,  following  a  suspicious  intercourse, 
is  always  strongly  suggestive,  on  its  face,  of  specific  urethritis. 

The  patient  who  comes  with  his  virginal  attack  of  gonorrhoea  is 
generally  totally  ignorant  of  the  virulent  nature  of  his  disease,  and  de- 
luded by  the  information  of  his  friends.  He  should  be  informed  that 
gonorrhoea,  badly  managed,  is  as  serious  a  matter,  in  many  cases,  as 
syphilis;  that  gonorrhoea  probably  kills  more  patients  than  syphilis  does, 
through  its  ultimate  effect,  by  means  of  stricture  of  the  urethra,  upon 
2 


18  VENEREAL  DISEASES. 

the  bladder  and  the  kidneys.  The  surgeon  should  refuse  in  any  case  to 
give  a  promise  of  cure  in  any  specific  time.  No  man  can  positively  assert 
at  the  start  whether  a  given  urethral  inflammation  just  commencing  at  the 
pouting  orifice  of  a  healthy  urethra  is  to  be  a  severe  case  or  not,  or  whether 
it  will  yield  a  prompt  response  to  remedies.  While  it  is  possible  to  settle 
at  once  the  question  of  specificity  by  microscopic  examination,  it  must 
not  be  forgotten  that  some  cases  of  so-called  non-specific  urethritis  have 
all  the  intensity  of  gonorrhceal  inflammation  and  may  run  a  prolonged 
course. 

If  a  man  has  already  had  several  attacks  of  gonorrhoea,  and  his  pres- 
ent attack  comes  on  without  any  osdematous  swelling  of  the  meatus 
urinarius,  the  chances  are  that  the  attack  will  be  a  mild  one.  If  the 
case  is  one  of  first  attack,  and  there  has  been  not  more  than  forty-eight 
hours'  incubation,  the  chances  also  are  that  the  inflammation  will  not  be 
violent.  If  there  has  been  no  sexual  intercourse  at  all  to  occasion  the 
new  outbreak,  the  course  of  the  malady  may  be  slow  and  its  duration 
protracted,  the  symptoms  may  or  may  not  run  high. 

Diagnosis. — The  diagnosis  of  acute  urethritis  is  generally  easy,  and  de- 
pends upon  the  presence  of  a  purulent  discharge  from  the  urethra  with  the 
attendant  symptoms  of  inflammation.  It  must  be  distinguished  from  a 
balano-posthitis  when  the  discharge  collects  between  the  glans  and  the 
prepuce  and  exudes  from  a  phimosed  opening. 

The  hypersecretion  of  the  glands  of  the  urethra  and  the  prostate  is 
of  a  non-purulent  character,  and  thus  is  recognized.  Sometimes  the  pres- 
ence of  a  chancre  within  the  urethra  will  cause  a  discharge  from  the 
meatus  and  mislead  the  surgeon,  but  a  short  lapse  of  time  will  generally 
bring  to  light  the  real  cause.  Having  excluded  the  above  sources  of  pos- 
sible error,  the  diagnosis  lies  between  specific  and  non-specific  urethritis, 
which  is  determined  by  bacteriological  examination. 

Finally,  when  the  gonococcus  is  sought  for  and  not  found,  and  the 
case  appears  to  be  one  of  a  succession  of  similar  attacks  which  have 
occurred  at  various  intervals,  structural  changes  in  the  urethra  or  morbid 
conditions  of  its  adnexa  are  generally  responsible  for  such  acute  outbreaks, 
and  must  be  located  by  appropriate  methods  when  the  acute  stage  subsides. 

Duration. — The  duration  of  non-specific  urethritis,  when  the  exciting 
cause  is  derived  from  alcoholic  excess  or  other  means  of  local  irritation, 
is  generally  short  and  readily  controlled  by  the  removal  of  such  cause. 

When  the  acute  inflammation  springs  from  a  urethra  already  the  seat 
of  structural  changes,  the  result  of  previous  trouble,  it  will  often  subside 
in  a  short  period  under  mild  treatment,  only  to  blossom  out  again  later 
when  sufficient  cause  recurs. 

Urethritis  occurring  in  rheumatic,  tuberculous,  and  cachectic  subjects 
is  more  apt  to  assume  a  severe  form,  and  to  extend  over  a  prolonged  period. 

Severe  non-specific  urethritis  and  its  prototype,  true  gonorrhoea,  vary 


SPECIFIC  AND   NON-SPECIFIC   URETHKITIS—  GONORRHOEA.         19 

in  the  length  of  their  duration  according  to  the  intensity  of  the  inflam- 
mation, the  treatment  employed,  and  the  time  at  which  treatment  is 
commenced. 

Formerly,  under  the  rational  measures  of  treatment  then  in  vogue,  a 
period  of  six  or  eight  weeks  was  considered  an  average  duration,  and  in 
severe  cases  longer  periods  were  not  considered  excessive.  At  the  pres- 
ent day  claims  are  made  of  effecting  a  cure  in  as  short  a  period  as  one 
week,  and  even  less.  In  spite  of  this,  however,  two  weeks  must  still  be 
considered  a  short  period  of  treatment,  three  weeks  a  reasonable  dura- 
tion, and  four  weeks  not  excessive. 

To  obtain  these  rapid  results  the  patient  must  be  seen  early  in  the 
career  of  his  disease,  and  the  treatment  continued  in  a  most  careful  but 
energetic  manner.  It  is  more  creditable  to  the  surgeon  to  conduct  a  case 
through  the  course  of  the  disease  free  from  complications  than  to  shorten 
its  duration  by  one  or  two  weeks. 

Treatment. — The  general  treatment  of  all  cases  of  urethritis  should 
aim  at  an  intelligent  observation  of  the  symptoms,  and,  according  to  the 
nature  and  intensity  of  a  given  case,  the  adoption  of  measures  hygienic, 
medicinal,  and  antiseptic. 

In  all  cases  of  gonorrhoeal  and  severe  cases  of  non-specific  urethritis 
hygienic  measures  and  absolute  regularity  of  life  should  be  enjoined  from 
the  start;  anything  like  irregularity  is  detrimental.  The  patient  should 
rest  as  much  as  possible,  lying  down  rather  than  sitting  or  walking.  He 
should  avoid  exercise  and  fatigue.  In  severe  cases  absolute  confinement 
may  shorten  the  period  of  the  disease  and  render  it  more  tractable  to 
treatment.  Eegularity  should  be  practised  in  sleeping  and  in  eating,  and 
particular  attention  should  be  bestowed  upon  the  function  of  the  intestine. 

The  amount  of  food  taken  should  be  moderate,  its  quality  bland  and 
unstimulating,  its  nature  light  and  varied.  If  the  patient  be  debilitated, 
on  the  other  hand,  plenty  of  meat  should  be  allowed,  the  full  ordinary 
amount  of  food  should  be  taken,  and  in  some  cases  even  a  little  red  wine, 
diluted  with  water,  from  the  very  beginning.  Milk  is  an  excellent  article 
of  diet  in  all  cases.  When  it  cannot  be  promptly  digested,  the  work  of 
the  stomach  may  be  made  easier  by  adding  salt  to  the  milk ;  and  a  laxa- 
tive, such  as  a  dinner-pill,  may  be  given  at  night,  or  a  little  compound 
licorice  powder,  or,  if  the  patient  prefers,  a  saline  aperient  water  in  the 
morning. 

Among  the  articles  of  food  to  be  avoided  in  all  acute  cases  (excepting 
those  coming  on  in  decidedly  debilitated  subjects,  when  intelligent  ex- 
ceptions must  be  made),  are  pastry,  gravies,  fried  fats,  and  greasy  articles 
of  food,  all  rich  made-dishes  and  indigestible  substances,  all  condiments 
of  every  description,  excepting  in  the  mildest  form.  Salt,  however,  is 
not  objectionable;  pickles  and  acids  usually  are.  Asparagus  is  harmful 
to  some  patients. 


20  VENEREAL,  DISEASES. 

Among  the  drinks  to  be  avoided  are  strong  coffee  and  tea;  all  wines 
and  liquors  of  any  description,  particularly  the  fermented  wines  and  malt 
liquors. 

Soda  water,  root  beer,  and  Vichy  water  may  be  used  as  beverages, 
and  the  more  water  that  can  be  taken  between  meals  the  better,  particu- 
larly one  of  the  diluent  mineral  waters  which  pass  rapidly  through  the 
kidneys.  It  is  always  well  for  patients  to  take  a  full  glass  of  water  upon 
retiring,  so  that  the  morning  urine  may  be  less  dense  than  would  other- 
wise be  the  case. 

Smoking  is  not  objectionable. 

Everything  which  tends  to  sexual  excitement,  whether  by  thoughts, 
conversation,  or  actions,  should  be  interdicted.  The  penis  should  be 
handled  as  little  as  possible. 

This  latter  precaution  must  be  strictly  enforced  for  two  reasons.  In 
the  first  place,  the  constant  pulling  at  the  urethra,  in  order  to  see  how 
much  pus  it  contains  and  what  its  quality  may  be,  is  irritating  to  the 
inflamed  mucous  membrane  of  the  canal.  In  the  second  place,  fingering 
the  urethra  exposes  the  eyes  of  the  patient  to  inadvertent  inoculation. 
The  caution  of  extreme  cleanliness  and  avoidance  of  the  contact  of  any 
pus  from  the  urethra  with  the  conjunctiva  should  be  very  forcibly  given 
to  each  patient,  and  frequently  repeated  and  insisted  upon. 

As  a  final  hygienic  precaution  it  is  well  for  the  patient  to  carry  his 
testicles  in  a  suspensory  bandage,  since  the  tendency  to  epididymitis  is 
in  this  way  decidedly  lessened. 

All  the  hygienic  precautions  alluded  to  should  be  held  in  force  during 
the  whole  course  of  an  urethral  discharge,  and  for  a  certain  period  after 
its  apparent  cessation  (a  week  to  ten  days),  through  fear  of  a  relapse. 
But  all  the  foregoing  restrictions  may  be  more  or  less  relaxed  in  mild 
non-specific  cases  of  urethritis. 

Internal  Treatment.— This  comprises  the  use  of : 

Alkalies  and  diuretics,  to  render  the  urine  bland  and  unirritating. 

Balsams,  santal  oil,  etc.,  which  act  favorably  upon  the  mucous  mem- 
brane of  the  urethral  tract  in  passing  out  of  the  system. 

Sedatives  and  anodynes,  to  lessen  ardor  urinte  when  intense,  and  con- 
trol chordee. 

Internal  antiseptics  are  sometimes  used  for  their  bactericidal  action. 
For  this  purpose  salol,  fifty  to  sixty  grains  daily,  or  methylene  blue,  two 
grains  three  times  a  day,  have  been  given  but  possess  no  established 
value. 

The  first  thing  to  be  done  in  severe,  notably  gonorrhceal  cases  is  to 
see  that  the  urine  be  made  abundant  and  alkaline,  so  that  it  may  be 
bland  and  unirritating  in  its  passage  over  the  inflamed  surface  of  the  ure- 
thral mucous  membrane.  To  accomplish  this  dilution  of  the  urine  it  may 
be  enough  to  take  an  extra  tumbler  of  water  several  times  a  day  between 


SPECIFIC   AND   NON-SPECIFIC   URETHRITIS — GONORRHCEA.         21 

meals.  Should  the  dilution  of  the  urine  not  materially  reduce  its  acidity, 
some  alkaline  drug  may  be  given  well  diluted  with  water,  and  adminis- 
tered during  the  third  hour 'after  each  meal. 

The  best  alkaline  drug,  in  cases  of  irritation  of  the  bladder  or  urethra, 
is  the  citrate  of  potash.  This  salt,  however,  is  unstable,  and  should 
always  be  obtained  from  a  reliable  pharmacist.  In  solution,  after  being 
kept  for  a  time,  it  becomes  changed  to  the  carbonate  of  potash.  The 
carbonate  of  potash,  although  a  fair  alkali,  is  not  so  good  a  diuretic  as 
the  citrate,  and  does  not,  as  a  rule,  agree  as  well  with  the  stomach. 

The  citrate  of  potash  may  be  given  in  doses  of  five,  ten,  or  fifteen 
grains  three  times  a  day,  according  to  the  effect  upon  the  urine.  Occa- 
sionally it  disagrees  with  the  stomach,  even  when  taken  in  small  amount. 
Under  such  circumstances  it  produces  a  sense  of  discomfort  in  the  region 
of  the  stomach,  perhaps  nausea,  possibly  diarrhoea,  and  sometimes  a 
pain  in  the  head  across  the  forehead.  In  these  cases  the  remedy  must 
be  discontinued,  and  some  other  alkali  tried.  Vichy  water  and  soda 
mint  tablets  may  answer  all  purposes,  one  or  two  of  the  latter  to  be  taken 
with  each  glass  of  vichy,  several  times  daily. 

If  the  case  be  one  in  which  there  is  reason  to  suspect  that  the  discharge 
comes  from  a  patch  of  damaged  urethra,  strictured  or  not,  which  has  been 
excited  to  suppuration — where,  for  instance,  a  drop  of  pus  appears  at  the 
beginning  of  the  attack  in  a  meatus  which  is  not  cedematous  or  swollen, 
in  such  a  case  there  is  sometimes  no  occasion  for  any  further  internal 
medication  than  the  alkaline  diuretics  already  alluded  to.  A  very  mild 
injection  may  be  used  at  once,  increased  in  strength  every  few  days;  and 
very  often  in  a  short  time  the  supposed  gonorrhoea  subsides,  and  the 
patient  rejoices  in  an  escape  from  a  prolonged  sickness  which  he  had 
perhaps  looked  upon  as  inevitable. 

Of  all  the  internal  remedies  in  vogue  there  is  none  more  generally 
efficacious  than  the  yellow  oil  of  sandal-wood.  This  may  be  given  in 
pearls  or  capsules,  ten,  fifteen,  or  twenty  minims  three  times  a  day. 

Sometimes  it  may  be  desirable  to  give  the  oil  and  the  alkali  combined 
in  a  single  prescription,  such  as  the  following,  which  is  not  unpalatable : 

E  Ol.  santali,     .        . §ss.-i. 

Liq.  potassse, .3  ij.-iv. 

Syr.  acaciae, .    §  i. 

Aquse  fceniculi, q.s.  ad    §  iij. 

M.     S.  Teaspoonful,  well  diluted,  after  eating. 

The  oil  of  gaultheria  may  be  substituted  for  the  sandal- wood  in  the 
above  prescription  in  the  same  proportion,  sometimes  with  good  effect. 
It  may  be  administered  alone  in  capsules.  In  like  manner  the  oil  of 
eucalyptus  may  be  preferred,  according  to  individual  peculiarities  in  a 
given  case. 

Sandal  oil  agrees  with  most  stomachs  much  better  than  copaiba.     It 


22  VENEREAL  DISEASES. 

produces  no  trouble  upon  the  skin,  and  is  not  apt  to  excite  diarrhoea. 
When  it  disagrees,  it  generally  does  so  by  causing  intense  pain  in  the 
back,  over  the  region  of  the  kidneys.  In  pushing  the  drug  to  obtain  its 
full  effect,  it  is  well  to  increase  the  dose  until  some  uneasiness  is  com- 
plained of  in  this  region,  and  then  to  reduce  it  for  a  day  or  more,  waiting 
for  the  pain  to  subside,  as  it  does  quite  promptly.  After  this  the  drug 
may  be  resumed  at  an  appropriate  dose. 

The  effect  of  sandal  oil  in  full  doses  is  usually  soothing  to  the  patient's 
sensations.  In  cases  of  ordinary  urethritis  it  often  promptly  modifies  the 
intensity  of  the  discharge.  In  true  gonorrhoea  it  is  less  effective,  and 
may  exert  no  influence  whatsoever  without  the  use  of  local  measures. 

The  balsam  of  copaiba  is  a  time-honored  remedy  for  urethral  inflam- 
mation, is  inexpensive  and  therefore  generally  quite  pure,  no  matter 
where  obtained.'  Copaiba  is  often  a  very  useful  drug  in  the  treatment  of 
urethritis,  but  it  is  nowadays  less  often  employed  when  much  reliance 
is  placed  upon  the  local  measures.  In  these  cases,  when  it  is  impossible 
or  inexpedient  to  use  local  means,  its  use  in  one  of  the  various  combina- 
tions may  prove  of  decided  value.  In  non-specific  urethritis  it  may  be 
used  at  any  period,  but  in  true  gonorrhceal  urethritis  it  is  more  suitable 
for  the  later  stages.  Indeed  in  some  instances  the  symptoms  of  gonorrhosa 
are  rendered  more  intense  by  the  too  free  use  of  balsams  (copaiba  or 
cubebs)  in  the  early  stage.  The  balsam  may  be  given  in  combination 
with  an  alkali,  in  a  prescription  similar  to  the  one  already  advised  for 
sandal-wood  oil,  or  in  one  of  the  following  mixtures : 

^  Bals.  copaibse, f  ss.-3. 

Liq.  potassse, 3  ij.-iv. 

Syr.  tolu, .3  iss. 

Extr.  glycyrrhizee, 3  ij. 

Aquae  menth.  pip., q.s.  ad    §  iij. 

M.    Shake.     S.  One  to  two  teaspoonfuls  at  a  dose. 

1$  Bals.  copaibse, 3  iv. 

Syr.  tolu, 

Syr.  acaciae, 

Aquae  menth.  pip. , aa   3  viss. 

M.     Shake.     S.  Teaspoonful  t.i.d. 

The  balsam  may  be  administered  in  an  endless  variety  of  combina- 
tions, mixed  with  sandal  oil,  with  cubebs,  and  in  countless  mixtures 
which  are  prepared  by  different  drug  houses  from  the  favorite  prescrip- 
tions of  various  physicians.  In  general,  the  method  by  tablets  or  cap- 
sules is  most  convenient  and  palatable,  since  the  drug  is  tasted  only 
•during  the  regurgitations  in  the  throat,  which  are  so  constant  and  offen- 
sive in  some  people  when  they  take  copaiba.  The  odor  of  the  balsam 
also  remains  on  the  breath,  and  is  quite  strong  in  the  urine  of  the  patient 
in  all  cases. 


SPECIFIC  AND  NON-SPECIFIC  URETHRITIS — GONORRHCEA.         23 

Copaiba  disagrees  with  many  patients.  It  causes  acute  indigestion 
in  some,  and  more  moderate  dyspepsia  in  others.  Sometimes  it  will  not 
stay  down  at  all,  but  is  rejected  by  the  stomach.  Occasionally  it  pro- 
duces headache  and  great  depression  of  spirits.  Sometimes  it  causes 
diarrhoea.  The  urine,  when  full  of  copaiba,  may  coagulate  under  heat  in 
a  manner  suggestive  of  the  presence  of  albumin. 

One  of  the  specific  effects  of  copaiba  is  to  produce  an  acute  eruptive 
disorder,  known  as  copaibal  roseola  or  erythema.  Its  advent  is  frequently 
announced  by  a  chill,  with  headache  and  nausea,  sometimes  by  diarrhoea 
and  considerable  fever.  The  eruption  is  general,  and  consists  of  red 
raised  blotches  which  itch  intensely. 

When  the  eruption  appears,  the  urethral  discharge  becomes  greatly 
modified,  or  ceases  entirely,  but  it  generally  returns  as  the  eruption 
fades. 

The  treatment  of  copaibal  erythema  is  to  give  plenty  of  fluids  by  the 
mouth,  and  bland  diuretics,  to  assist  the  kidneys  in  eliminating  the 
offending  substance  from  the  blood.  Warm  baths  are  comforting,  espe- 
cially if  they  contain  a  little  baking-soda — about  one  ounce  to  thirty  gal- 
lons— or  some  of  the  infusion  of  bran,  as  in  the  ordinary  bran-bath. 
Dusting  the  skin  with  starch-powder  is  cooling,  and  a  few  days  generally 
suffices  so  to  moderate  the  eruption  that  the  itching  is  no  longer  distress- 
ing. On  the  first  appearance  of  this  eruption  the  copaiba  must  be 
stopped ;  but  it  may  be  resumed  again,  if  it  be  desired,  in  smaller  doses, 
after  the  eruption  is  well  on  the  decline. 

Cubebs  is  another  remedy  which  has  stood  the  test  of  time ;  it  may 
be  administered  as  a  powder,  or  in  drachm-doses  of  the  fluid  extract. 
The  oleoresin  is  a  very  useful  preparation,  notably  in  the  subacute  and 
chronic  cases  and  in  the  declining  stage  of  acute  urethritis;  not  in  the 
early  stage.  The  dose  is  from  ten  to  thirty  minims,  and  it  may  be  ad- 
ministered in  various  ways.  Small  quantities  are  easily  taken  upon  a 
lump  of  sugar,  larger  doses  best  in  capsules.  One  capsule  at  a  dose  is 
enough  to  begin  with,  to  be  gradually  increased.  Patients  generally  halt 
at  three  capsules  at  a  dose,  but  sometimes  they  take  four. 

The  effect  of  cubebs  in  moderate  doses  is  rather  to  stimulate  digestion 
and  act  as  a  tonic.  The  breath  smells  of  it,  and  the  urine  is  full  of  its 
odor.  Large  doses  are  distinctly  irritating  to  the  stomachs  of  most 
patients,  and  cause  diarrhoea,  with  griping  pain.  If  the  neck  of  the 
bladder  happens  to  be  at  all  congested,  or  if  the  organ  tends  to  be  irri- 
table, cubebs  is  generally  harmful,  since  it  aggravates  such  conditions, 
and,  if  pushed,  may  go  so  far  as  to  bring  on  inflammation  of  the  neck  of 
the  bladder.  If  the  local  antiseptic  treatment  of  gonorrhoeal  urethritis  is 
objected  to  and  an  antiphlogistic  regime  is  preferred,  the  proper  manner 
of  adopting  such  a  course  is  to  hold  to  the  use  of  alkalies  and  diluents 
until  the  acute  .symptoms  subside,  and  then  to  resort  to  the  use  of  cubebs 


24  VENEREAL.  DISEASES. 

and  copaiba  during  the  last  stage.  Guiard  of  Paris  commends  this  course 
in  all  cases. 

Turpentine  is  sometimes  distinctly  useful  in  the  declining  stage,  and 
in  subacute  or  chronic  cases  of  urethritis ;  it  may  also  be  given  in  those 
cases  in  which  cubebs  does  not  agree.  The  oil  of  turpentine  may  be 
taken  upon  a  lump  of  sugar,  in  five-  to  twenty-drop  doses,  three  or  four 
times  a  day.  If  preferred,  it  may  be  given  very  conveniently  in  the 
form  of  the  pearls  of  turpentine  (TTI,  v.),  as  they  are  called,  prepared  by 
various  manufacturers.  The  dose  of  these  is  from  one  to  three. 

Sometimes  turpentine  acts  as  an  irritant,  just  as  cubebs  does,  and 
induces  frequent  urination.  In  such  case,  the  remedy  must  be  changed 
or  the  dose  lessened.  The  tincture  of  cantharides  has  somewhat  the 
same  range  of  action  as  turpentine,  but  should  be  still  more  exclusively 
confined  in  its  use  to  the  subacute  and  chronic  stages.  It  is  given  in 
Til  iii.-vi.  doses  three  times  daily,  well  diluted. 

One  of  the  following  combinations  of  the  above  preparations,  which 
are  put  up  in  capsules  by  different  chemists,  may  be  chosen  according  to 
the  lights  of  the  physician  and  the  peculiarities  of  different  cases : 


Copaibse,  TH,  vi. 

Cubeb.ol.resin.,TH,  ij. 
01.  santal.,         TIJ,  ij. 


Copaibse,     TTJ,  v. 
01.  santal.,  TH,  v. 


Copaibse,  Til  iij. 

01.  resin,  cubeb.,  m,  iij. 
01.  resin,  matico,  fft,  i. 
01.  santal.,  TTJ,  iij. 


Salol.,  gr.  iiss. 

01.  santal.,  TH,v. 
Pepsin.,        gr.  i. 


The  oil  of  sandal-wood  and  salol  are  suitable  to  all  stages  of  acute 
urethritis,  but  the  other  combinations  to  the  subacute  and  chronic  cases 
and  to  the  later  stages  of  acute  urethritis. 

When  chordee  and  ardor  urinae  become  severe  in  spite  of  the  use  of 
alkalies  and  diluents,  it  is  necessary  to  employ  additional  remedies  to  con- 
trol these  symptoms.  Sometimes  the  addition  of  a  small  amount  of 
codeine,  gr.  £  -  £  three  times  a  day,  may  be  sufficient  to  palliate  them. 
This  may  be  given  in  a  tablet  triturate  or  added  to  the  liquid  mixture. 
A  large  dose  of  codeine  (gr.  ii.),  given  at  night,  may  prevent  chordee. 
Phenacetin  (gr.  v.  or  x.),  lupulin  (gr.  xxx.-lx.),  and  bromide  of  potas- 
sium (gr.  Ix.-xc.)  are  sometimes  taken  for  the  same  purpose  before  re- 
tiring. The  objection  to  lupulin  is  that  it  is  very  bulky,  and  to  the 
bromide  that  it  upsets  the  stomach  in  such  full  doses. 

The  tincture  of  hyoscyamus  is  an  excellent  remedy  for  controlling  the 
ardor  urinse.  It  may  be  administered  in  one  of  the  mixtures  already 
mentioned : 

1$  Codeine  [spts.  rect.  q.a.  ad  sol.],       .        .        .        .  gr.  iij.-vi. 

Ol.  santal  i  (or  gaultheria,  or  eucalyptus),  .         .         .  |  ss. 

Tinct.  hyoscyami, 3  iss. 

Liq.  potassse, .         .  3  ij. 

Syr.  acaciae, q.s.  ad  |  iij. 

M.     S.  Teaspoonful  three  times  a  day. 


SPECIFIC   AND   NON-SPECIFIC   URETHRITIS — GONORRHOEA.         25 

In  this  mixture  the  codeine  need  not  be  included  unless  needed.  The 
oil  may  also  be  removed  and  given  instead  in  capsule  form. 

Finally,  some  cases  of  non-specific  urethritis,  which  occur  as  a  result 
of  an  oversensitive  state  of  the  urethra,  accompanying  diathetic  condi- 
tions, anaemia,  and  malnutrition,  require  such  internal  remedies  as  will 
directly  benefit  the  underlying  condition.  Iron  and  arsenic  as  general 
tonics,  cod-liver  oil  and  creosote  for  some  cases,  will  at  times,  in  addition 
to  the  local  or  internal  treatment  already  instituted,  be  the  means  of 
bringing  about  a  favorable  result. 

Before  proceeding  to  the  consideration  of  the  local  treatment  of  acute 
urethritis,  attention  should  be  called  to  the  fact  that  there  are  two 
methods  in  vogue  of  treating  this  malady,  either  one  of  which  may  result 
in  a  safe  and  complete  cure,  but  with  a  decided  difference  in  the  period 
of  duration. 

The  antiphlogistic  method  recommended  particularly  by  Fournier  and 
Guiard  of  Paris,  and  others,  disapproves  of  the  employment  of  any  local 
measures  in  the  early  stage  when  the  acute  symptoms  run  high,  but  relies 
upon  the  free  use  of  alkaline  diuretics  and  diluents  during  this  period, 
which  is  intended  to  permit  the  discharge  to  flow  freely  without  restric- 
tion, and  only  when  the  discharge  has  materially  decreased  and  the  acute 
stage  has  subsided  are  local  measures  adopted.  The  latter  consist  of 
astringent  injections  in  some  form  or  of  irrigations. 

The  alternative  course,  and  the  one  recommended  in  this  book,  consists 
in  the  adoption  of  local  measures  at  the  onset  of  the  inflammation,  for 
the  purpose  of  destroying  or  restraining  the  microbic  agents  and  curtail- 
ing the  attack  of  the  disease. 

LOCAL  TREATMENT. 

The  local  measures  adopted  in  the  treatment  of  urethritis  should  vary 
according  to  the  nature  and  intensity  of  the  inflammation. 

The  judicious  use  of  local  applications  in  specific  urethritis  is  the 
most  important  feature  in  the  treatment  of  this  malady  when,  the  pres- 
ence of  the  gonococcus  having  been  established,  it  is  desired  to  cut  as 
short  as  possible  the  stay  of  this  micro-organism  in  the  urethra. 

In  cas^s  of  non-specific  urethritis,  intense  and  active,  local  measures 
play  an  important  role  in  the  treatment;  while  in  mild  non-specific 
cases,  and  those  which  depend  upon  diathetic  and  constitutional  causes, 
such  means  are  often  unnecessary,  and  may  even  be  the  cause  of  prolong- 
ing the  symptoms. 

The  different  therapeutic  agents  adopted  for  urethral  medication  are 
intended  to  exert  germicidal,  astringent,  or  stimulating  effects,  as  the 
case  may  require,  and  are  employed  by  means  of  copious  irrigations> 
instillations  or  injections,  and  in  soluble  bougies. 


26  VENEREAL  DISEASES. 

The  Abortive  Treatment  of  Gonorrhoea. — It  is  generally  conceded 
that  an  abortive  treatment  of  gonorrhoea,  to  be  successful,  must  be 
resorted  to  within  a  few  hours  after  the  first  appearance  of  the  urethral 
discharge.  While  many  of  the  local  antiseptics,  commonly  employed  at 
the  present  time,  have  the  effect  of  shortening  the  course  of  a  gonorrhoea, 
they  cannot  strictly  be  considered  as  abortive  measures.  A  treatment 
which  is  deserving  of  this  title  must  quash  the  disease  at  its  onset  and 
prevent  its  evolution.  For  this  purpose  the  permanganate  of  potassium 
has  been  employed  in  strong  solutions  (1  :  500  and  1  : 1, 000)  by  copious 
irrigations  of  the  anterior  urethra  a  few  hours  after  the  discharge  appears ; 
also  the  nitrate  of  silver  (2-4  per  cent  solution)  and  corrosive  sublimate 
(1 : 1,000),  which  are  injected  with  an  ordinary  urethral  syringe  with  a 
capacity  of  about  two  drachms.  The  pain  and  distress  following  the  use 

of  these  injections   are  very  in- 

tlJ        A^     ^^    ^1^      tense,   but  when  successful  the 
sero-sanguinolent  discharge, 
'*     '™      which     subsequently      appears, 
subsides  in  a  day  or  two  of  its 

own  accord.  This  treatment  is  harsh,  and  seldom  employed 
for  this  reason,  and  because  the  patient  is  not  seen  early 
enough.  Its  success  depends  upon  the  destruction  of  the 
gonococci  before  they  have  penetrated  beneath  the  epithelial 
lining  of  the  urethra. 

Astringent  Injections. — Injections    of   the  urethra  are 
capable  of  rendering  considerable  service  in  urethritis,  but 
FIG.  i.  when  improperly  used  they  may  occasion  much  mischief. 

In  gonorrhceal  urethritis,  if  they  are  used  at  the  be- 
ginning of  the  disease,  there  is  grave  danger  of  carrying  the  inflamma- 
tion backward  and  of  lighting  up  posterior  urethral  complications,  espe- 
cially when  the  agent  employed  possesses  astringent  properties  only 
and  is  not  destructive  to  the  gonorrhoeal  virus. 

In  specific  urethritis,  then,  if  the  local  treatment  is  not  directly  antag- 
onistic to  the  life  of  the  gonococcus,  such  as  may  be  obtained  by  copious 
irrigations  of  the  urethra  with  permanganate  of  potassium  or  by  the  local 
application  of  the  silver  preparations,  it  is  far  better  to  follow  the  treat- 
ment advised  by  Fournier,  Guiard,  and  others,  and  postpone  all  local 
measures  until  the  later  stage,  when  the  acute  symptoms  shall  have 
subsided.  It  is  at  this  late  stage  that  the  judicious  use  of  a  mild  astrin- 
gent injection  may  sometimes  be  of  service. 

Frequently  in  subacute  urethritis  and  in  non-specific  cases  generally 
one  of  the  astringent  injections  may  be  employed  with  good  effect.  It 
is  often  the  case,  however,  that  the  discharge,  which  is  checked  by  the 
use  of  an  injection,  promptly  returns  when  such  injection  is  discontinued. 
This  relapsing  urethritis  is  generally  due  to  morbid  changes  in  the  urethra 


SPECIFIC   AND  NON-SPECIFIC   URETHRITIS — GONORRHCEA.         27 

and  to  underlying  constitutional  conditions.  Such  cases  of  relapsing 
urethritis  which  persistently  recur  properly  come  under  the  head  of 
chronic  urethritis  (i-ide  page  37). 

A  final  precaution  concerning  the  use  of  injections  is  that  they  occa- 
sionally produce  and  keep  up  a  discharge  on  account  of  being  inappro- 
priately strong.  This  is  quite  likely  to  occur  with  those  patients  who 
frighten  themselves  into  the  belief  that  they  have  gonorrhoea  when  such 
does  not  exist,  and  who  commence  a  fierce  onslaught  on  the  urethra  with 
injections — a  treatment  which  promptly  excites  a  flow  of  pus  and  confirms 
their  fears.  On  the  other  hand,  at  the  end  of  a  gonorrhoea,  when  an 
injection  of  undue. strength  has  been  employed  to  arrest  the  discharge, 
an  oozing  of  gleety  mucus  may  keep  up,  maintained  by  the  use  of  a 
strong  injection  which  is  persisted  in. 

In  either  one  of  this  class  of  cases  rapid  improvement  follows  a  cessa- 
tion of  the  injection. 

In  injecting  the  urethra  a  proper  syringe  should  be  used,  'one  which 
is  not  too  blunt  nor  yet  which  is  made  with  too  long  a  nozzle.  This 
may  be  varied  according  to  the  size  of  the  rneatus  in  an  individual  case 
(Fig.  1).  In  order  to  obtain  the  proper  degree  of  distention  of  the 
canal,  the  capacity  of  such  a  syringe  should  be  between  2  and  3^  drachms. 
The  syringe  is  filled  with  the  injection  and  the  air  expelled.  The  penile 
end  is  introduced  snugly  within  the  mouth  of  the  meatus  and  the  fluid 
injected  by  making  firm,  steady  pressure  upon  the  piston.  The  contents 
of  the  syringe  having  been  thus  emptied  into  the  urethra,  the. latter  is 
withdrawn  and  the  fluid  retained  by  closure  of  the  meatus  with  the 
thumb  and  index  finger  for  ten  seconds  for  an  astringent  injection ;  much 
longer  when  the  object  is  to  destroy  micro-organisms  as  with  one  of  the 
silver  preparations.  It  is  always  proper  to  urinate  before  making  the  in- 
jection, thereby  emptying  the  canal  of  any  accumulated  discharge. 

The  different  astringent  preparations  used  for  urethral  injection  are 
zinc  sulphate,  sulpho-carbolate,  and  permanganate,  alum,  subacetate  of 
lead,  bismuth,  and  fluid  extract  of  hydrastis.  One  of  the  following 
formulae  may  be  employed : 

R  Zinci  sulphatis, gr.  iij.-vi. 

Liq.  pluinbi  subacetatis  dilut.,          .        .         .        .     §  iv. 
M.     To  be  filtered. 

R  Zinci  sulphatis, gr.  iv. 

Bismuth., 3  ij. 

Pulv.  acacise, 3  i- 

Aquae, q.s.  ad  §  iv. 

M.     To  be  well  shaken. 

R  Zinci  permanganat., gr.  i.-iv. 

Aquae, §  iv. 

M. 


28 


VENEREAL.   DISEASES. 


!£  Zinci  sulphatis,  ........  gr.  ij.-iv. 

Ext.  hydrastisfld., .    3  i.-iv. 

Aquse, •        •        •        •    §  iv. 

M. 

3  Aluminis, '       .         .         .  gr.  iv.-viij. 

Zinci  sulphatis, gr.  ij.-iv. 

Aquae,          .        ."•...'       •  -.'.•        •         •         •         .    §  iv. 
M. 

The  frequency  with  which  the  above  astringent  preparations  should 
be  used  must  be  governed  by  the  quantity  of  the  discharge  and  the  con- 
trolling influence  exerted  upon  it  by  the  injection.  A  proper  rule  to 
follow  is  to  use  the  injection  only  sufficiently  often  to  keep  the  discharge 
in  check.  When  the  discharge  persists  in  spite  of  its  usage  after  a  rea- 
sonable length  of  time,  or  when  relapses  occur  as  often  as  the  injection 
is  discontinued,  it  may  be  taken  as  an  indication  that  the  agent  employed 
is  acting  as  a  source  of  irritation  rather  than  a  means  of  relief,  or  that 
there  is  trouble  deeper  down  the  canal  than  is  reached  by  the  injection 
(posterior  urethritis)  or  perhaps  deeper  in  the  tissues  themselves. 

Urethral  and  Intra-Vesical  Irrigations. — The  method  of  irrigating  the 
urethra  in  the  treatment  of  gonorrhoea  is  not  new.  It  was  used  over  ten 
years  ago  by  different  investigators,  notably  by  Halstead,  of  Baltimore, 
and  Brewer,  of  New  York,  who  employed  the  bichloride  of  mercury  for  this 
purpose.  More  recently  the  permanganate  of  potassium  has  come  into 
popular  favor  on  account  of  its  marked  destructive  action  upon  the  gono- 
coccus,  and  of  the  admirable  results  reported  in  its  use  by  Janet,  of  Paris> 
who  has  carefully  laid  down  a  method  of  treatment  which  bears  his  name. 
Janet's  method  is  shown  in  the  accompanying  table,  which  is  extracted 
from  the  treatise  of  Dr.  Desnos,  of  Paris:1 


8 

A.M. 

Afternoon. 

9  P.M. 

First  day  

Second  day  
Third  day  

*A. 

tA. 

U. 

p. 

1: 
U. 

3,000.  . 
1:2,000 

*A. 

U.  1: 

1, 

000... 

•A. 

*A. 
tA. 
tA. 

U.  1  :  4,000 

7  P.M. 

U.  1  :  4,000. 
P.  U.  1  :  4,000 
P.  U.  1  :  4,000 

Fourth  day  

\  A 

P.  U. 

1 

:  2,000 

Fifth  day  

tA. 

p. 

U. 

1  :  2,000 

Sixth  day  

fA. 
fA. 
tA. 
tA. 
tA. 

P.  U. 
P.  U. 
P.  U. 
P.  U. 
P.  U. 

1 
1 

1 
1 
1 

:  2.000 
1,000 
:  1,000 
:  1,000 
:  1,000 

Seventh  day  

Eighth  day  

Ninth  day  

Tenth  day  

*A. 

r. 

1: 

500  

*  A.  U.  =  anterior  urethral  irrigation. 

t  A.  P.  U.  =  anterior  and  posterior  urethral  irrigation. 

The  anterior  irrigation  is  conducted  by  means  of  a  conical-shaped 
nozzle  fitted  to  the  meatus,  and  a  fountain  syringe  or  irrigator.     The 

1  "Traite  eleinentaire  des  Maladies  des  Voies  urinaires  "  par  le  Dr.  E.  Desnos, 
1898 


SPECIFIC   AND   NON-SPECIFIC   URETHRITIS — GONORRHOEA. 


29 


posterior  urethra  is  irrigated  with  the  same  nozzle  by  distending  the 
anterior  urethra  with  the  solution  and  raising  the  reservoir  to  a  height 
sufficient  to  overcome  the  resistance  of  the  cut-off  muscle  (between  six  and 
eight  feet).  The  method  of  Janet,  as  shown  in  the  above  table,  is  too 
dogmatic.  The  treatment  can  be  best  utilized  by  varying  the  strength  of 
the  permanganate  solution  according  to  the  susceptibility  and  sensitive- 
ness of  different  urethras.  We  find  that  weaker  solutions  in  the  begin- 
ning of  the  disease  are  better 
tolerated  and  produce  the  same 
results. 

It  is  entirely  unnecessary 
in  the  early  stages  of  the  dis- 
ease to  extend  the  irrigation  to 
the  posterior  urethra.  In  some 
cases  recovery  occurs  before 
this  region  is  reached  by  the 
disease  when  it  need  not  be  in- 
vaded by  the  treatment  at  all. 
In  other  cases  not  so  favorable, 
at  the  expiration  of  a  week  or 
ten  days,  the  proximity  of  the 
inflammation  is  likely  to  be 
such  that  the  posterior  canal 
should  be  irrigated  as  a  matter 
of  precaution  if  not  necessity. 

The  method  of  forcing  the  resistance  of  the  cut-off  muscle  is  also  un- 
necessary, and  is  likely  to  cause  undue  irritation  when  the  inflammation 
of  the  urethra  is  acute.  Swelled  testicle  has  often  been  produced  by  it. 
Even  if  it  be  a  safe  procedure  in  the  hands  of  one  specially  trained  and 
practised  in  its  use,  it  is  not  proper  to  advise  it  as  a  routine  method. 

In  employing  the  Janet  method  we  begin  with  a  solution  of  1  :  5,000 
or  6,000  permanganate  of  potassium,  and  increase  the  strength  during  the 
first  week  up  to  1  :  4,000.  The  treatment  is  given  once  or  twice  daily  in 
the  early  stage  of  the  disease ;  generally  once  a  day  is  sufficient  to  keep 
the  discharge  under  control,  if  not  it  should  be  employed  twice  daily.  At 
the  end  of  the  first  week  or  ten  days  the  irrigation  includes  both  the 
anterior  and  posterior  urethras,  iinless  the  case  has  proved  a  very  tractable 
one  and  all  symptoms  have  subsided  before  this  period.  This  treatment 
is  not  stopped  abruptly,  but  continued  after  the  discharge  has  ceased  and 
both  floAvs  of  urine  are  clear,  at  which  period  an  interval  of  one  or  two 
days  is  allowed  to  intervene  between  the  treatments.  The  method  of 
applying  this  treatment,  which  has  proved  most  satisfactory,  is  carried 
out  by  means  of  a  special  instrument  (Figs.  4,  5,  6)  designed  for  this  pur- 
pose, and  enables  the  operation  to  be  conducted  without  damage  and  with- 


FiG.  2.— Chetwood's  Alternating  Shut-off. 


30 


VENEREAL  DISEASES. 


out  dirt.     It  permits  a  moderate  amount  of  distention  of  the  canal,  which 
is  essential,  and  provides  for  the  emptying  of  the  urethra  without  with- 


FIG.  3. — Chetwood's  Urethral  Nozzles. 

drawal  of  the  nozzle  of  the  instrument.  A  catheter  was  formerly  used 
for  irrigating  the  anterior  urethra,  but  is  unsatisfactory  as  it  does  not 
produce  a  proper  distention  of  the  canal.  An  ordinary  cone-shaped  nozzle, 
which  must  be  withdrawn  after  each  inflation  to  empty  the  canal,  is  un- 
wieldy and  less  cleanly. 

The  distinctive  parts  of  this  apparatus  for  urethral  and  intravesical 
irrigation  consist  of  a  glass  nozzle  (Fig.  3),  which  has  one  large  open- 
ing at  its  penile  extremity,  connecting  with  two  arms,  one  for  the  inflow 
and  one  for  the  outflow  current,  and  the  alternating  shut-off  (Fig.  2), 


Pio.  4.— Anterior  Urethral  Irrigation.    The  Irrigating  fluid  Is  allowed  to  fill  the  nozzle  to  displace  the 
air  before  coupling,  and  Is  retained  by  the  little  flnger  over  the  exit  tube. 


SPECIFIC  AND   NON-SPECIFIC   URETHRITIS — GONORRHCEA.         31 

which  is  intended  to  open  and  shut  the  tubes  attached  to  the  two  arms  of 
the  nozzle  alternately;  so  that  by  impeding  the  outflow  current,  when  the 
fluid  enters  the  urethra,  an  even  distention  of  the  canal  is  produced;  and 
by  obstructing  the  inflow  current  after  the  urethra  is  full,  complete  ejec- 
tion of  its  contents  is  insured.  The  amount  of  distention  is  regulated 
by  the  height  of  the  reservoir,  four  and  a  half  to  five  feet  being  sufficient 
to  irrigate  the  entire  anterior  section  of  the  canal  and  produce  the  proper 
amount  of  distention.  The  pressure  may  be  varied  when  pain  is  com- 


FiG.  5.— Anterior   Urethral  Irrigation.     The  foreskin  is  retracted  and  the  nozzle  coupled  with  the 
meatus,  when  the  fluid  is  allowed  to  enter  the  urethra  by  opening  the  shut-off. 

plained  of,  by  partially  closing  the  inflow  tube.  This  apparatus  may  be 
used  to  irrigate  the  posterior  urethra  without  a  catheter  by  elevating  the 
reservoir  sufficiently  to  overcome  the  resistance  of  the  cut-off  muscle  (six 
to  eight  feet) .  In  acute  urethritis  it  is  well  to  employ  the  catheter  for 
posterior  irrigation,  having  previously  thoroughly  irrigated  the  anterior 
canal. 

For  posterior  urethral  irrigation  a  No.  6  or  7  English  catheter  is  care- 
fully lubricated 1  and  slowly  introduced  until  a  few  drops  of  urine  indicate 
that  the  bladder  is  reached.  Before  attaching  the  irrigating  tube  to  the 
catheter  the  bladder  is  completely  emptied,  after  which  the  catheter  is 
withdrawn  about  one  inch  so  as  to  direct  the  flow  between  the  membra- 

1  A  soluble  lubricant  should  be  employed  so  as  not  to  arrest  the  action  of  the 
irrigating  fluid.  "Lubri-chondrin,"  which  is  made  from  Irish  moss,  and  several 
saponaceous  lubricants  possess  this  property. 


32 


VENEREAL,  DISEASES. 


nous  and  prostatic  urethras  and  thus  insure  distention  of  the  entire  pos- 
terior urethra.  When  the  bladder  is  filled  the  catheter  is  entirely  with- 
drawn and  the  patient  is  told  to  void  the  vesical  contents  by  urinating. 
About  one  quart  of  solution  is  used  for  anterior  irrigation  and  from  eight 
to  twelve  ounces  for  the  posterior  portion,  according  to  the  capacity  of 
the  bladder. 

It  is  of  great  importance  in  acute  urethritis  to  irrigate  thoroughly  the 
anterior  urethra  before  introducing  the  catheter  into  the  posterior  canal. 


FIG.  6.— Anterior  TJrethral  Irrigation.    The  urethra  being  distended  the  shut-off  is  closed,  which  opens 
the  outflow  tube  and  the  urethra  promptly  empties. 

Attention  to  this  detail  may  be  the  means  of  avoiding  unnecessary  com- 
plications. 

The  permanganate  of  potassium  irrigations,  while  used  more  particu- 
larly in  specific  urethritis,  are  also  applicable  to  the  treatment  of  non-speci- 
fic cases,  notably  those  in  which  the  discharge  is  profuse  and  purulent,  the 
difference  in  the  management  being  that  it  is  rarely,  if  ever,  necessary 
in  the  latter  form  to  irrigate  more  than  once  a  day,  and  the  posterior 
urethra  need  never  be  invaded  unless  it  is  apparent  that  the  inflammation 
is  located  in  this  region. 


THE  TOPICAL  USE  OF  THE  SILVER  COMPOUNDS. 

The  nitrate  of  silver  has  long  been  employed  as  a  topical  application  for 
inflammatory  conditions  of  the  urethra.  Its  use  as  an  abortive  measure  in 
gonorrhoea  has  already  been  referred  to.  Its  value  depends  upon  its  bacter- 


SPECIFIC  AND  NON-SPECIFIC   URETHRITIS — GONORRHOEA.        33 

icidal  action,  which  is  especially  directed  against  the  gonococcus.  In  view 
of  this  valuable  property  of  the  silver  salts  and  of  certain  disadvantages 
attributed  to  the  nitrate,  there  have  been  introduced  several  new  silver  com- 
pounds, all  of  which  claim  to  possess  the  bactericidal  action  of  the  nitrate 
and  to  be  devoid  of  its  objectionable  features.  These  preparations  are 
the  citrate  of  silver  of  Crede,  argentamin,  argonin,  and  protargol.  The 
nitrate  of  silver  is  a  good  local  antiseptic  for  urethral  use  in  solutions 
from  1  :  2,000  to  1  :  500.  It  is  applicable  to  both  the  specific  and  non- 
specific forms  of  acute  urethritis.  It  is  applied  to  the  anterior  urethra  by 
means  of  an  ordinary  urethral  syringe  (Fig.  1)  or  with  the  Keyes-TTltz- 
inann  syringe  (see  Fig.  18,  page  46) ;  but  the  beneficial  effects  of  this  and 
of  all  the  silver  preparations  are  more  especially  obvious  in  the  last  stage 
of  urethritis,  when  the  acute  symptoms  have  subsided,  notably  as  a  deep 
urethral  application  in  posterior  urethritis  by  means  of  the  deep  urethral 
syringe.  The  nitrate  of  silver  is  thus  employed  in  increasing  strength,  be- 
ginning at  1  :  1,000  aud  increasing  according  to  the  tolerance  of  the  ure- 
thra in  each  individual  case.  Such  applications  are  made  at  intervals  of 
one,  two,  or  three  days,  and  are  often  the  means  of  terminating  the  last 
stage  of  a  gonorrhoea  after  it  has  reached  the  deep  urethra. 

The  disadvantages  attributed  to  the  nitrate  of  silver  are  that  it  stains 
the  linen  and  the  hands,  is.  more  or  less  irritating,  and  that  it  precipitates 
the  albumin  of  the  tissues,  thus  limiting  its  range  of  action.  Regarding 
these  objections,  the  first  renders  it  unsuitable  for  the  patient's  own  use; 
the  second  depends  more  or  less  upon  the  strength  of  the  solution  and  the 
individual  susceptibilities  of  different  urethras,  while  in  spite  of  the  third 
objection  it  seems  to  exert  its  influence  somewhat  deeper  than  the  perman- 
ganate of  potassium  does,  although  it  does  not  check  the  discharge,  when 
copious,  as  well  as  the  latter  remedy.  The  citrate  of  silver  and  argenta- 
rrin  will  not  be  found  less  irritating  than  the  nitrate  or  more  effective. 
Argonin  may  be  used  in  much  stronger  solutions  without  causing  irrita- 
tion (five  to  ten  per  cent),  but  relapses  sometimes  occur  during  its  use  in 
acute  specific  urethritis,  showing  that  it  permits  the  gonococcus  to  get 
beyond  its  reach. 

Protargol  has  been  used  in  the  clinic  of  Lewin  and  Frank  of  Berlin, 
and  by  Neisser,  apparently  with  gratifying  results  in  acute  gonorrhreal 
urethritis.  Its  employment  is  recommended  in  a  solution  of  one-half  to 
ono  per  cent,  to  be  retained  in  the  urethra  for  half  an  hour  once  a  day 
and  ten  minutes  twice  a  day.  The  gonococci  are  said  to  disappear  per- 
manently from  the  urethra  in  from  two  to  five  days.  When  used  in  the 
last  stage  of  gonorrhoea  in  the  posterior  urethra  in  place  of  the  nitrate,  it 
should  be  employed  in  stronger  solutions  than  in  the  anterior  urethra, 
beginning  with  two  and  a  half  per  cent  and  working  up,  if  possible,  to 
ten  per  cent.  In  this  stage  we  believe  it  to  be  of  more  value  than  in  the 
acute  condition,  in  which  it  is  inferior  to  the  permanganate  of  potassium. 
3 


34 


VENEREAL   DISEASES. 


The  claims  of  superiority  of  these  various  silver  compounds  over  the 
nitrate  are  not  universally  indorsed.  When  the  daily  office  attendance 
necessitated  by  the  irrigation  treatment  is  too  exacting  upon  the  patient 
in  cases  of  specific  urethritis,  a  five-per-cent  solution  of  argonin  or  of 
one-half  per  cent  protargol  may  be  ordered  for  the  patient's  own  use,  to 
be  employed  by  means  of  an  ordinary  urethral  syringe,  with  a  capacity 
of  2  or  2^  drachms  two  or  three  times  daily,  and  good  results  may  follow 
such  treatment.  In  some  instances  these  injections  have  been  employed 
in  conjunction  with  the  permanganate  of  potassium  irrigations.  This 
combination  of  both  the  irrigations  aud  the  silver  preparations  applies, 
of  course,  to  the  specific  form  of  the  disease. 

A  resume  of  the  local  means  to  be  adopted  in  the  treatment  of  acute 
urethritis  is  as  follows :  When  the  conduct  of  the  treatment  can  be  entirely 
under  the  control  of  the  surgeon,  the  good  results  attained  by  the  use  of 
copious  irrigations  of  the  urethra  with  permanganate  of  potassium  strongly 


FIG.  7.— Gonorrhoea  Bag. 


recommend  this  mode  of  treatment  before  all  others.  The  silver  prepara- 
tions, argonin  and  protargol,  may  be  used  by  the  patient  in  specific  ure- 
thritis when  the  more  exacting  treatment  is  impracticable.  A  combina- 
tion of  the  irrigation  treatment  with  the  judicious  use  of  one  of  the  silver 
preparations  is  serviceable  in  some  cases  of  acute  specific  urethritis.  The 
application  to  the  posterior  urethra  of  the  nitrate  of  silver  or  of  protargol 
will  often  assist  in  terminating  the  last  stage  of  urethritis,  and  it  is  at 
this  period  that  the  silver  preparations  seem  to  exercise  their  most  bene- 
ficial effect. 

Finally  the  use  of  the  astringent  injections  by  means  of  an  ordinary 
urethral  syringe  is  more  applicable  to  subacute  non-specific  cases  of  ure- 
thritis, although  sometimes  of  service  in  the  declining  stage  of  gonor- 
rhoea, when  the  specific  element  has  been  destroyed. 

The  dressings  of  the  penis  in  urethritis  when  the  discharge  is  abundant 
become  a  matter  of  importance,  and  may  prevent  the  occurrence  of  bala- 
mtis  and  posthitis,  and  vegetations  around  the  foreskin,  all  of  which 
conditions  are  frequently  due  to  the  collection  of  irritating  discharges. 


SPECIFIC   AND   NON-SPECIFIC   URETHRITIS — GONORRHCEA.         35 

When  the  discharge  from  the  penis  is  slight  and  of  a  non-purulent 
character,  a  plug  of  cotton,  dry  or  moistened  with  mild  sublimate  solu- 
tion, placed  over  the  meatus  and  retained  by  the  prepuce,  may  be  a 
sufficient  dressing;  but  when  copious  it  is  necessary  to  provide  some- 
thing better  to  catch  the  flow  and  protect  the  clothing.  Gonorrhoea  bags, 


FlQ.  8. 


FIG.  9.  FIG.  10. 

FIGS.  8,  9,  and  10. — Dressing  for  Gonorrhoea. 

made  of  rubber  or  muslin,  are  sold  by  druggists  for  this  purpose  (Fig. 
7).  The  bag  is  suspended  from  the  waist  by  means  of  tapes,  and  a 
piece  of  absorbent  cotton,  dry  or  moistened  with  an  antiseptic  solution, 
is  placed  inside.  The  cotton  should  be  changed  frequently.  Another 
satisfactory  dressing,  worn  in  connection  with  an  ordinary  suspensory 
bandage,  consists  of  a  piece  of  absorbent  gauze,  folded  in  the  shape  of  a 


36  VENEREAL  DISEASES. 

triangle.  The  base  of  this,  about  ten  inches  wide,  is  placed  underneath 
the  penis,  and  the  three  corners  are  folded  over  and  pinned  together  to  the 
band  of  the  suspensory  (Figs.  8,  9,  10).  Such  a  dressing  may  be  changed 
as  frequently  as  is  necessary,  according  to  the  amount  of  discharge.  In 
all  cases  general  cleanliness  should  be  strictly  observed.  The  discharge 
should  not  be  allowed  to  accumulate  behind  the  foreskin.  A  mild  anti- 


C.TIEMANNiCO 

FIG.  11.— Taylor's  Duckbill  Syringe. 

septic  wash  should  be  employed  daily,  and  if  the  foreskin  cannot  be 
retracted,  a  duckbill  syringe  (Fig.  11)  should  be  used  to  wash  the  cav- 
ity of  the  prepuce.  For  purposes  of  general  cleanliness,  as  well  as  when 
balanitis  or  posthitis  exist,  a  solution  of  corrosive  sublimate,  1  :  6,000  or 
8,000,  may  be  used,  or  the  following  astringent  and  antiseptic  lotion: 

3  Thymol, gr.  i. 

Sulpho-carbolate  of  zinc, gr.  i. 

Boracic  acid, 3  i. 

Fluid  extract  of  hydrastis  (colorless),        .        .        .        .  3  ij. 

Aqua  gaultherise, q.s.  ad  §  iv. 


CHAPTER  II. 

CHKONIC  UKETHKITIS. 

Etiology. — Chronic  urethritis  is  generally  the  result  of  a  prolonged, 
neglected,  or  ill-treated  gonorrhoea.  It  may  occur,  however,  independ- 
ently of  gonorrhoea,  notably  in  subjects  of  a  gouty,  rheumatic,  or  tubercu- 
lous diathesis.  It  also  seems  to  be  the  case  that  tuberculous  and  rheumatic 
subjects  who  acquire  gonorrhoea  are  more  liable  than  others  to  posterior 
urethritis  and  other  complications,  as  well  as  to  the  protraction  of  the 
malady  into  the  chronic  condition  commonly  called  gleet. 

Clinically  speaking,  we  recognize  several  forms  of  chronic  urethritis : 
First,  one  which  is  in  direct  continuation  of  recent  acute  inflammation, 
in  which  the  symptoms  are  pronounced  and  the  discharge  of  a  variable 
character,  often  rather  free.  This  may  last  anywhere  from  three  to  six 
months,  even  longer. 

In  the  second  form  the  discharge  is  decidedly  scanty,  and  has  been 
present  for  a  much  longer  period — perhaps  for  years. 

A  third  form  shows  itself  as  a  continual  tendency  to  recurring  attacks 
of  acute  or  subacute  urethritis,  between  which  there  may  be  practically 
no  signs  of  trouble.  These  several  forms  are  dependent  upon  various 
causes.  The  first  may  be  due  to  the  continued  stay  of  the  gonococcus  in 
the  urethra,  to  constitutional  debility,  to  the  existence  of  complications, 
or  to  badly  directed  treatment,  and  sometimes  to  too  long  continued  or 
too  energetic  local  measures.  The  second  and  third  forms  are  generally 
dependent  upon  stricture  or  other  morbid  changes  in  the  urethra  or 
adjacent  structures,  catarrhal  and  mildly  inflammatory  conditions  excited 
into  activity  by  various  causes — intercourse,  alcohol,  fatigue,  etc. — or  are 
dependent  upon  diathetic  conditions,  gout,  scrofula,  tubercle,  etc.  Ac- 
cording to  some  recent  investigators  it  is  rare  to  find  the  gonococcus  in 
very  old  cases  of  chronic  urethritis. 

Pathology. — When  the  urethra  has  been  the  seat  of  several  attacks  of 
acute  and  intense  gonorrhoea,  notably  if  complicated  and  not  properly 
controlled  by  treatment,  the  general  tissue  and  follicles  are  apt  to  become 
structurally  altered  in  a  mild,  chronic,  inflammatory  way,  and  thus  to 
render  the  subject  prone  to  frequent  acute  outbreaks  from  causes  which 
do  not  affect  the  mucous  membrane  when  it  is  healthy.  Chronic  urethritis 
may  be  located  in  the  anterior  or  posterior  urethra,  or  both.  A  favorite 
site  in  the  anterior  urethra  is  the  sinus  of  the  bulb,  but  the  trouble  may 
be  disseminated  throughout  the  spongy  portion.  The  morbid  changes 


38  VENEREAL  DISEASES. 

consist  in  alterations  in  the  color  and  transparency  of  the  mucous  mem- 
brane, structural  changes  in  the  epithelium,  alterations  in  the  follicles 
and  glands,  which  may  become  distended  with  retained  pus,  their  ducts 
being  dilated  or  occluded,  or  the  glands  may  become  obliterated  as  the 
result  of  formation  of  new  fibrotic  tissue.  Finally  granulations  form  on 
the  surface  of  the  mucous  membrane,  a  starting-point  of  stricture.  In 
the  posterior  urethra  the  changes  are  more  or  less  analogous,  but,  owing 
to  the  structures  liable  to  be  involved,  the  condition  here  becomes  more 
important  and  the  symptoms  are  more  complex.  The  mucous  membrane 
is  swollen  ami  congested ;  the  veru  montanum  elevated  and  softened ;  the 
glands  and  follicles  present  the  same  changes  as  in  the  anterior  urethra, 
and  one  or  both  of  the  ejaculatory  ducts  may  become  catarrhal  or  even 
occluded.  The  inflammation  in  the  prostatic  canal  may  result  in  engorge- 
ment of  the  neck  of  the  bladder,  and  eventually  in  contracture  of  the 
sphincter  (see  Prostatitis) . 

Symptoms. — In  chronic  anterior  urethritis  the  discharge  is  continuous. 
It  may  be  slight  and  the  quantity  may  be  greater  on  rising  in  the  morn- 
ing, but  this  is  due  to  over-night  accumulation.  It  may  be  so  scanty  as 
to  cause  a  slight  glueing  together  of  the  meatus,  or,  on  the  other  hand, 
it  may  be  continuously  copious.  In  the  latter  instance  the  existence  of 
anterior  urethritis  is  self-evident,  although  there  may  coexist  posterior 
urethral  inflammation.  The  discharge  is  practically  the  only  symptom 
present  in  chronic  anterior  urethritis,  as  there  is  generally  no  pain  or 
other  discomfort.  By  obtaining  the  urine  in  two  separate  flows  it  will 
be  seen  that  the  second  is  perfectly  clear ;  or,  having  previously  washed 
out  the  anterior  canal,  the  urine  voided  will  be  found  entirely  free  from 
pus.  If  a  conical  bulbous  bougie  be  passed  into  the  anterior  urethra  (a 
bulb  as  large  as  the  meatus  will  admit)  down  to  but  not  into  the  mem- 
branous portion,  when  the  urethritis  is  confined  to  the  anterior  canal,  a 
tender  spot  may  be  detected  somewhere  along  the  urethra  during  the 
introduction  of  the  instrument;  and  when  it  is  withdrawn,  a  small 
amount  of  pus  will  generally  be  found  upon  the  shoulder  of  the  bulb. 
The  damaged  area  in  this  manner  may  be  located  in  the  bulb,  in  the 
fossa  navicularis,  or  in  some  part  of  the  urethra  between  these  points. 
In  the  case  of  multiple  strictures  the  site  of  the  inflammatory  area  will 
be  found  behind  the  points  of  contraction. 

In  chronic  posterior  urethritis,  unless  accompanied  by  anterior  inflam- 
mation, the  discharge  is  intermittent.  When  slight  it  appears  only  in 
the  passage  of  the  urine,  but  when  more  abundant  collects  at  the  meatus 
in  the  form  of  a  morning  drop,  or  the  flow  may  be  provoked  by  the  act 
of  straining  at  stool.  There  is  not  uncommonly  a  certain  amount  of 
frequency  of  urination ;  the  desire  is  urgent  but  not  imperative,  and  ac- 
companied by  more  or  less  burning  at  the  end  of  the  penis.  When  the 
pain  and  the  desire  to  urinate  persist  after  the  urine  is  voided,  it  is  an 


CHRONIC    URETHRITIS. 


39 


indication  that  the  neck  of  the  bladder  is  involved,  and  when  there  is 
pain  in  the  perineum  in  the  intervals  between  urination,  there  exists  in 
conjunction  with  the  urethritis  a  prostatitis.  In  exploring  the  urethra 
with  a  blunt  steel  or  bulbous  instrument,  after  previously  washing  the 
anterior  canal,  it  will  be  noted  that  no  pus  is  expressed  from  the  anterior 
region ;  but  as  soon  as  the  posterior  urethra  is  reached,  a  sharp  pain  is 
produced,  and  the  withdrawal  of  the  instrument  is  accompanied  by  a  dis- 
charge of  pus.  Of  course  when  this  condition  exists  in  a  very  mild  de- 
gree, the  amount  of  discharge  obtained  may  be  minute,  but  the  sensitive 
area  will  have  been  located  in  the  region  where  the  trouble  exists. 

Endoscopic  examination  is  useful  for  the  anterior  urethra,  and  will 
reveal  the  general  condition  of  the  mucous  membrane.  The  mouths  of 
distended  follicles  may  be  distin- 
guished if  pus  exudes  from  them, 
and  we  may  detect  the  presence  of 
granulations  or  warty  excrescences  on 
the  urethral  surface.  For  the  pos- 
terior urethra  the  endoscopic  exami- 
nation is  less  useful.  It  is  produc- 
tive of  great  pain,  and  sometimes 
the  source  of  unnecessary  irritation. 

Diagnosis. — In  reaching  a  diag- 
nosis regarding  the  location  of  chronic 
urethritis,  it  should  be  remembered 
that  the  discharge  is  liable  to  be 
continuous  in  anterior  and  intermit- 
tent in  posterior  urethritis ;  that  the 

symptoms  of  urgent,  frequent,  and  painful  passage  of  the  urine' are  absent 
in  anterior  and  may  or  may  not  be  present  in  posterior  urethritis.  Unless 
there  coexist  a  certain  amount  of  cystitis,  these  latter  symptoms  are  not 
marked.  The  urine  should  be  voided  in  two  separate  glasses,  the  urethra 
having  been  previously  carefully  washed  with  plain  lukewarm  water. 
The  washings  will  thus  contain  the  product  of  the  front  urethra,  the  first 
flow  of  urine  the  posterior  urethral  pus,  and  the  second  the  urine  as  it 
exists  in  the  bladder.  The  bulbous  bougie  or  blunt  sound  will  detect  the 
contracted  or  sensitive  areas,  and  in  making  these  explorations  it  is 
important  to  separate  in  the  examination  the  anterior  and  posterior  por- 
tions of  the  canal. 

Urethroscopy  is  au  additional  means  of  diagnosis,  and  in  some 
instances  renders  important  service.  For  this  purpose  various  instru- 
ments have  been  devised,  the  principal  difference  being  in  the  manner  of 
obtaining  the  required  light  for  direct  observation  of  the  urethral  tract. 
The  simplest  and  most  available  method  for  ordinary  usage  is  the  head 
mirror.  Instead  of  a  head  mirror  an  electric  head  lamp  with  a  condenser 


FIG.  12.— Electric  Head  Lamp. 


40 


VENEREAL  DISEASES. 


has  been  devised  (Fig.  12) .     Another  means  of  reflecting  the  light  into 
the  urethra  is  obtained  by  the  Otis  urethroscope,  in  which  the  reflector  and 


FIG.  13.— Otis  Urethroscope. 


light  are  connected  directly  with  the  endoscopic  tube  (Fig.  13).  The  more 
complicated  recent  device,  the  Oberlander-Nitze  urethroscope,  brings  the 
light  within  the  urethra  by  the  use  of  a  platinum  wire,  which  is  heated  to 
incandescence  (Fig.  14).  This  requires  the  addition  of  a  cooling  apparatus 


FIG.  14.— Oberlander-Nitze  Urethroscope. 


to  enable  the  urethra  to  withstand  comfortably  the  presence  of  the  light 
and  involves  the  employment  of  an  expensive  and  complicated  attachment. 
A  new  urethroscope  has  recently  been  devised  which  is  an  improvement 
on  previous  makes  and  has  the  light  within  the  urethra.  It  is  a  modifi- 
cation of  Kollman's  modification  of  the  Oberlander  instrameut,  the  prin- 


FIG.  15.— Klotz  Endoscopic  Tube. 


cipal  feature  being  that  no  cooling  apparatus  is  required.  For  urethro- 
scopic  examination  we  may  employ  a  speculum  or  an  endoscopic  tube 
(Figs.  15,  16,  and  17)  of  a  size  suitable  to  the  capacity  of  the  urethra 
(Plate  VIII.). 


KEYES   AND   CHETWOOD. 


PLATE  VIII. 


1.  Instrument     in     use 
with  endoscopic  tube. 

2.  Same,  with  wire  spec- 
ulum in  place  of  tube. 

3.  Mignon    incandescent 
lamp  used  for  illumination. 

4.  Light  carrier  with  pro- 
tected lamp  for  use  in  a 
speculum.    Especially  use- 
ful for  intra-urethral  opera- 
tions.   Does  not  burn  the 
canal. 

5.  Unprotected       lamp 
used  with   light  carrier  in 
endoscopic    tube  for  ordi- 
nary urethroscopy. 

6.  Apparatus    complete, 
with  battery.    Dimensions, 
10  in.  X  5^  in.  X  2)4  in. 


CHETWOOD  URETHROSCOPE,  FOR  DIRECT  ILLUMINATION  OF  THE  URETHRA  WITHOUT  HEAT. 


CHRONIC   URETHRITIS. 


41 


It  is  possible  for  the  ordinary  observer  to  recognize  granulations, 
papillomata,  and  erosions  in  the  different  portions  of  the  anterior  ure- 
thra, but  it  requires  the  eye  of  an  accomplished  and  prac- 
tised worker  to  interpret  the  various  endoscopic  pictures  of 
a  less  definite  and  more  complex  character  which  are  some- 
times described,  and  by  an  intelligent  adoption  of  the  other 
methods  in  vogue  it  will  be  found  that  it  is  only  in  excep- 
tional cases  that  urethroscopy  is  essential  to  obtain  a  satis- 
factory diagnosis. 

As  already  stated,  direct  examination  cf  the  posterior 
urethra  is  more  difficult  and  less  satisfactory. 

When   the   symptoms   of   urethritis   point  toward  the 
existence  of  inflammation  of  the  prostate  gland, 
digital  examination  by  rectal  touch  will  deter- 
mine the  condition  of  this  organ  as 
well  as  that  of  the  seminal  vesicles. 
The  existence  of  cystitis  in  conjunc- 
tion with  urethritis  will  be  recognized 
by  the  symptoms  and  by  the  examina- 
tion of  the  urine.     These   complica- 
tions are  to  be  considered  in  a  later 
chapter. 

Treatment.  —  The  treatment  of 
chronic  urethritis  must  be  varied  ac- 
cording to  the  nature  and  character  of 
the  malady.  In  that  class  of  cases  in 
which  the  inflammation  is  a  direct  con- 
tinuation of  recent  acute  urethritis,  all 
the  restrictions  as  regards  the  use  of 
stimulants,  sexual  excitement,  etc., 
are  to  be  enforced  as  in  the  acute  con- 
dition. Indeed  its  prolongation  into 
the  chronic  stage  is  often  due  to  a 

failure  to  observe  these  precautions.     As  already  stated,  chronic  urethri- 
tis may  be  due  to  the  continued  stay  of  the  gonococcus  in  the  urethra, 


FIG.  16.— Otis  Endoscopic  Tubes. 


FIG.  17.— Brown's  TJrethral  Speculum. 


42  VENEREAL  DISEASES. 

to  the  existence  of  one  of  the  various  complications  which  occur  during 
the  acute  stage,  to  constitutional  debility,  and  sometimes  to  too  long- 
continued  local  treatment.  That  class  of  cases  in  which  the  discharge  is 
very  slight,  and  has  existed  for  a  considerable  period,  is  generally  more 
difficult  to  treat.  The  cause  is  apt  to  be  some  structural  change  in  the 
canal  itself,  or  extension  of  inflammation  to  the  adjacent  structures.  The 
treatment  of  these  cases  therefore  entails  the  discovery  of  the  underlying 
cause  and  its  treatment  by  proper  measures.  Stricture  of  the  urethra, 
chronic  prostatitis  and  vesiculitis  are  common  causes,  and  are  considered 
in  a  separate  chapter. 

Finally,  those  cases  which  appear  as  frequent  relapses  of  urethritis 
from  causes  which  should  not  affect  the  healthy  urethra,  are  generally  the 
result  of  changes  wrought  in  the  tissues  by  the  previous  inflammation, 
and  more  often  occur  in  subjects  of  a  tuberculous,  gouty,  or  rheumatic  dia- 
thesis. In  studying  the  various  forms  of  chronic  urethritis  we  must  take 
into  consideration  the  following  elements,  which  may  enter  into  any  given 
case: 

1.  The  presence  of  the  gonococcus  in  the  urethra. 

2.  Too  long-continued  or  irritating  local  treatment. 

3.  Structural  changes  in  the  urethra  and  extension  of  inflammation  to 
the  neighboring  parts. 

4.  Constitutional  debility  and  diathetic  conditions. 

A  careful  analysis  of  each  case  should  discover  one  or  more  of  the 
above  causative  factors,  and  determine  the  course  of  treatment  to  be 
followed.  When  rigorous  local  measures  have  been  pursued  for  a  long 
period  without  controlling  the  discharge,  often  by  instituting  a  simple 
antiphlogistic  regime,  more  favorable  results  will  follow.  Under  these 
circumstances,  the  cessation  of  local  measures  and  the  use  of  internal 
medication  alone  or  in  conjunction  with  milder  local  means  should  be  tried. 

When  the  gonococcus  is  discovered  in  the  discharge  from  the  urethra 
local  measures  to  antagonize  its  presence  there  should  be  adopted.  Local- 
ized morbid  conditions  in  the  canal  or  adjacent  structures  should  besought 
out  and  treated  according  to  the  indications.  Concomitant  constitutional 
disorders  should  as  far  as  possible  be  corrected  by  rational  treatment. 

Internal  Treatment. — The  nearer  a  case  of  chronic  urethritis  ap- 
proaches to  the  acute  form  in  its  character,  the  more  appropriate  are  those 
internal  remedies  referred  to  in  the  treatment  of  the  latter  malady.  Thus 
when  the  discharge  is  more  or  less  free,  the  use  of  the  oil  of  sandal  wood 
or  of  oil  of  gaultheria  alone,  or  in  combination  with  an  alkali,  is  indicated. 
The  oleoresin  of  cubebs  and  the  oil  of  turpentine  are  suitable  for  the  more 
chronic  and  less  active  forms ;  TT[  v.  to  xx.  of  the  former  or  TTJ,  v.  to  x.  of 
the  latter  may  be  given  three  times  daily.  The  oil  of  eucalyptus  is  some- 
times given  with  good  effect,  m  v.  to  x.  three  times  a  day.  When  the  poste- 
rior urethra  or  the  adjoining  portion  of  the  bladder  is  the  seat  of  trouble, 


CHRONIC   URETHRITIS.  43 

attention  is  called  to  a  greater  or  lesser  amount  of  urinary  tenesmus  and 
urgency,  which  may  be  present.  For  this  train  of  symptoms  the  tincture 
of  hyosc}Tamus  and  the  fluid  extract  of  corn  silk  are  useful  adjuvants; 
TH,  xv.  to  xxx.  of  the  former  and  3  ss.  to  3  i.  of  the  latter  may  be  given 
after  each  meal  in  combination  with  the  other  remedies.  When  the  urine 
is  highly  concentrated  and  irritating  it  should  be  diluted  by  the  free  use 
of  diuretic  mineral  water.  The  tincture  of  hyoscyamus  and  fluid  extract 
of  kava  kava  both  have  desirable  diuretic  properties,  and  may  be  given 
for  this  purpose,  exerting  at  the  same  time  a  certain  amount  of  sedative 
influence  upon  the  posterior  urethra.  Finally,  iron,  cod-liver  oil,  and 
hypophosphites  are  to  be  used  when  the  general  health  calls  for  such 
medication. 

FORMULAE. 

R  01.  gaultheriae, .  f  ss. 

Potass,  cit., 3  ij. 

Tinct.  hyoscyami, 3  vi. 

Ext.  fld.  stigmat.  maidis, §  i. 

Syr.  acacise, q.s.  ad  §  iij. 

M.     S.  Teaspoonful  t.i.d. 

1$  Capsul.  ol.  terebinth., TH,V. 

S.  One  or  two  t.i.d. 

Or: 

Capsul.  ol.  eucalyptus, Tl  v. 

S.  One  or  two  t.i.d. 

Or: 

Capsul.  ol.  santal., iH,x. 

S.  One  or  two  capsules  t.i.d. 

R  Capsul.  oleoresin.  cubebse, iHX.      */ 

S.  Four  to  six  capsules  daily. 

R  Bals.  copaibse, 

Ol.  gaultheriae, &a   §  ss. 

Liq.  potass., 3  iij. 

Syr.  acacise, q.a.  ad  §  iij. 

M.     S.  Teaspoonful  t.  i.d. 

R  Ext.  fld.  kavse  kavae, 

Ext.  fld.  stigmat.  maidis, fia§ij- 

M.     S.  One  to  two  teaspoonfuls  t.i.d. 

Local  Treatment. — The  statement  made  concerning  internal  medication 
should  be  repeated  here,  that  the  nearer  the  character  of  the  symptoms 
of  chronic  urethritis  approaches  the  acute  form  the  more  suitable  are 
those  measures  employed  during  the  acute  stage.  Thus  when  the  dis- 
charge is  free  and  purulent,  the  use  of  irrigations  of  permanganate  of 
potassium,  both  to  the  anterior  and  posterior  urethra,  is  indicated.  The 
permanganate  of  potassium  and  the  silver  preparations  are  especially  to 


44  VENEREAL  DISEASES. 

l)e  relied  upon  when  the  presence  of  the  gonococcus  has  been  demon- 
strated. Instrumental  dilatation  of  the  urethra  once  or  twice  a  week  in 
connection  with  the  other  treatment  of  chronic  urethritis,  aside  from  its 
employment  in  stricture  of  the  canal,  is  at  times  a  desirable  measure. 
Such  dilatation  opens  the  follicles  of  the  urethra  and  expresses  their  con- 
tents, keeps  down  granulations,  and  lessens  irritability  and  tendency  to 
spasm.  Some  urethras  rebel  against  any  instrumental  interference,  and 
should  not  be  submitted  to  it  except  from  strict  necessity.  The  smooth 
steel  sound,  deftly  handled,  is  the  least  irritating  urethral  instrument. 
The  largest  size  that  the  meatus  will  admit  should  be  employed,  and  no 
undue  force  used  in  its  passage.  Other  dilating  instruments  have  been 
devised,  and  are  used  for  the  same  purposes  as  the  sound.  They  are 
constructed  so  as  to  be  expanded  to  any  size  after  introduction,  the  size 
being  indicated  on  a  dial  at  the  handle  (p.  133).  They  are  also  made  to 
combine  dilatation  with  irrigation.  The  objection  to  dilators  generally 
has  been  that  the  blades  of  the  instruments  which  are  covered  with  a 
soft-rubber  hood  make  a  less  even  distention  than  the  sound  and  cause 
more  irritation.  By  having  a  sound  which  is  tapering  in  both  directions 
(Fig.  67,  page  126),  the  meatus  need  not  be  submitted  to  the  same  amount 
of  distention  as  the  lower  portion  of  the  canal,  while  the  sound  is  doing 
its  work  at  the  point  where  distention  is  most  needed. 

Urethral  medication  is  effected  by  means  of  irrigations,  instillations, 
injections,  soluble  bougies,  antiseptic  applications,  and  cupped  sounds. 

By  means  of  injections  or  bougies  the  patient  can,  if  desired,  conduct 
the  local  treatment  himself  when  it  is  confined  to  the  anterior  urethra. 
Injections  are  by  far  the  more  satisfactory. 

The  other  methods  mentioned  are  carried  out  by  the  surgeon. 

Cupped  sounds  are  intended  to  be  used  for  the  application  of  ointment 
to  the  surface  of  the  urethra,  but  are  not  so  much  in  vogue  at  the  present 
time  as  they  were  formerly. 

The  use  of  the  endoscope  is  often  irritating,  and  should  be  confined  to 
those  cases  in  which  there  exists  a  well-defined  local  lesion  which  can  be 
readily  reached,  such  as  a  papilloma  or  ulceration. 

It  is  a  mistake  to  proceed  to  the  treatment  of  any  case  of  chronic  ure- 
thritis in  a  routine  manner.  A  proper  analysis  of  each  case  will  greatly 
assist  in  the  selection  of  treatment.  The  existing  lesion  should,  if  pos- 
sible, be  located,  and  any  functional  irregularity  or  constitutional  dis- 
turbance taken  into  account. 

Many  cases  of  chronic  urethritis  (anterior  or  posterior)  get  well  as  the 
result  of  well-directed  local  treatment,  while  others  get  well  when  local 
treatment,  which  has  been  too  long  continued,  is  stopped.  Some  pa- 
tients who  are  undermined  in  general  health,  or  the  subjects  of  the  tuber- 
culous or  scrofulous  diathesis,  either  improve  or  get  entirely  well  when 
transplanted  to  a  favorable  climate,  while  those  patients  in  whom  the  ure- 


CHRONIC   TJRETHRITIS.  45 

thritis  is  due  to  structural  changes  in  the  canal  (stricture,  etc.)  necessarily 
do  not  improve  unless  treatment  be  directed  against  the  actual  lesion. 

The  use  of  astringent  injections  by  the  patient  is  sometimes  of  value 
in  correcting  a  simple  catarrhal  condition,  and  may  control  the  discharge 
from  the  anterior  urethra.  They  are  also  used  to  supplement  the  local 
treatment  conducted  by  the  surgeon,  or  when  enforced  absence  of  the 
patient  precludes  the  adoption  of  other  measures.  For  this  purpose  one 
of  the  astringent  injections  given  on  page  27  may  be  ordered. 

Urethral  bougies  are  cylinders  of  cacao  butter  containing  some  medica- 
ment. They  are  retained  in  the  urethra,  and,  melting,  liberate  the  drug. 
In  this  manner  the  nitrate  of  silver,  sulphate  of  copper,  sulphate  of  zinc, 
iodoform,  and  numerous  other  substances  have  been  employed.  This 
form  of  medication  is  sometimes  a  source  of  irritation  and  the  means  of 
lighting  up  fresh  inflammation,  and  has  nothing  to  recommend  it  in 
preference  to  the  more  popular  methods  in  use. 

Irrigations  of  permanganate  of  potassium  of  mild  strength  (1  :  8,000 
to  1 : 4, 000)  are  best  suited  to  caSes  in  which  the  discharge  is  profuse  or 
the  urine  more  or  less  turbid  with  pus.  Its  favorable  effects  are  generally 
so  promptly  obvious  that  when  some  improvement  is  not  noted  soon  after 
a  short  trial,  it  may  be  safely  concluded  that  the  permanganate  is  not 
what  is  required,  and  recourse  should  be  had  to  other  means  of  relief. 

The  anterior  urethra  alone  is  irrigated  when  the  trouble  is  confined 
to  this  region.  The  method  has  been  already  described  (p.  29).  When 
the  posterior  urethra  is  the  seat  of  trouble,  posterior  irrigation  is  em- 
ployed, always  after  previously  irrigating  the  anterior  canal,  if  there  be 
any  evidence  of  trouble  in  that  part. 

These  irrigations  are  generally  made  at  intervals  of  one,  two,  or  three 
days,  according  to  the  amount  of  pus  secreted  and  the  control  exercised 
upon  this  secretion  by  the  treatment,  until  a  stationary  period  is  reached, 
as  evidenced  by  the  cessation  of  the  discharge  and  the  reduction  of  the 
pus  in  the  urine  to  a  minimum  quantity.  Sometimes  no  other  treatment 
is  required,  but  a  certain  amount  of  inflammation  may  persist  which  tends 
to  remain  under  the  permanganate  more  or  less  stationary,  and  may  be 
benefited  by  the  substitution  of  one  of  the  other  local  applications,  more 
astringent  in  action  and  somewhat  more  penetrating.  At  this  period 
instillations  are  frequently  found  useful,  and  in  some  cases  of  chronic 
urethritis  prove  more  effective  than  the  permanganate  irrigations  from 
the  very  beginning  of  the  treatment. 

Instillations  are  suitable  for  both  the  anterior  and  posterior  urethra. 
They  are  employed  with  the  Keyes-Ultzmann  or  Guyon  syringes  (Figs. 
18  and  19),  by  means  of  which  small  quantities  of  solutions  possessing 
astringent,  antiseptic,  and  mildly  caustic  properties  are  distributed  along 
the  course  of  the  canal.  The  Guyon  instrument  consists  of  a  flexible 
gum-elastic  catheter  with  a  bulbous  end,  having  a  small  opening  at  the 


46  VENEREAL  DISEASES. 

top.  A  Pravaz  syringe  is  fitted  to  the  catheter,  and  its  contents  are  ejected 
drop  by  drop  by  turning  the  piston,  which  is  a  screw.  The  Keyes  in- 
strument is  solid  in  one  piece,  consisting  of  a  silver  catheter  with  fine 


FIG.  18.— Keyes'  Deep  TTrethral  Syringe. 

lumen  and  proper  urethral  curve,  attached  to  a  small  syringe,  the  piston 
of  which  is  graduated  in  minims.  The  introduction  of  this  latter  syringe 
is  seemingly  less  irritating  than  that  of  a  bulbous  instrument,  and  permits 
the  application  of  the  liquid  to  any  portion  of  the  canal,  whether  in  the 
anterior  or  posterior  urethra.  When  the  medicament  is  intended  for  the 
anterior  urethra,  the  syringe  may  be  introduced  as  far  as  the  sinus  of  the 
bulb,  and  its  contents  ejected  as  the  instrument  is  being  slowly  with- 
drawn (Fig.  20).  The  liquid  when  applied  to  any  portion  of  the  anterior 
urethra  will  naturally  escape  from  the  meatus,  but  should  be  retained  by 
compressing  the  lips  of  the  meatus  for  a  period  of  about  one  minute.  When 
the  application  is  made  to  the  membranous  or  prostatic  portions  of  the 
canal,  it  does  not  escape  upon  withdrawal  of  the  instrument,  but  is  retained 
by  the  compressor  urethras  muscle.  To  reach  the  membranous  urethra  the 
syringe  is  passed  into  the  sinus  of  the  bulb  and  the  tip  of  the  instrument, 
by  gentle  pressure,  is  made  to  penetrate  just  inside  the  triangular  liga- 
ment (Fig.  21).  For  the  prostatic  portion  it  is  introduced  by  downward 
pressure  about  three-quarters  of  an  inch  farther.  Twenty-five  to  thirty 
minims  of  liquid,  which  is  the  regular  capacity  of  the  Keyes  syringe, 
are  generally  injected  with  each  instillation.  Larger  quantities  of  mild 
solutions  may  be  introduced  by  having  a  syringe  with  larger  barrel 


FIG.  19.— Guyon's  Syringe. 


(3i—  3  iss.},  but  when  a  very  strong  solution  of  silver  nitrate  is  em- 
ployed much  smaller  quantities   are   required,    sometimes   only  a   few 
-rops.     The  bladder  should  be  emptied  prior  to  making  an  instillation  to 
e  posterior  urethra,  that  the  neck  of  the  bladder  may  be  also  bathed 
with  the  injected  fluid. 


CHRONIC   URETHRITIS. 


47 


Of  the  various  agents  employed  for  urethral  instillation  the  following 
are  selected  as  being  worthy  of  special  notice :  sulphate  of  thallin,  sul- 
phate of  copper,  nitrate  of  silver,  protargol,  ichthyol. 

The  sulphate  of  thallin  is  mildly  astringent,  antiseptic,  and  in  weak 
solutions  somewhat  sedative  in  its  action.  It  has  been  used  in  two-  to 
two-and-one-half-per-cent  solution  as  an  anterior  injection  in  gonorrhoea, 
but  its  employment  for  this  purpose  has  been  practically  abandoned.  As 
an  instillation  to  the  posterior  urethra  in  solutions  of  three  to  twelve  per 


FIG.  20.— Anterior  Urethral  Instillation. 

cent,  its  most  favorable  effect  is  produced,  which  in  some  instances  is 
strikingly  satisfactory. 

In  mild  cases  of  posterior  urethritis  in  which  the  discharge  is  slight 
and  mucoid  in  character,  when  the  deep  urethra  is  hypersesthetic,  stands 
instrumental  interference  poorly,  and  is  irritated  by  the  use  of  other 
applications,  the  sulphate  of  thallin  will  often  prove  of  decided  value. 
Neuralgic  pains,  which  radiate  through  the  posterior  urethra,  possibly 
induced  by  congestion  remaining  after  the  subsidence  of  a  more  active 
condition,  will  sometimes  yield  to  it.  Being  about  the  mildest  of  all  the 
deep  urethral  instillations,  it  is  also  used  to  lead  up  to  the  stronger  appli- 
cations when  they  are  not  at  first  well  tolerated. 

This  preparation  may  be  conveniently  kept  on  hand  in  a  twelve-per- 
cent solution,  and  diluted  for  use  to  the  desired  strength.  It  'should  be 
dispensed  in  a  dark-colored  bottle  to  prevent  exposure  to  the  light.  The 
beneficial  effect  of  this  remedy  is  generally  obtained  by  the  use  of  a  solu- 


48 


VENEREAL  DISEASES. 


tion  of  from  four  to  twelve  per  cent.  The  quantity  injected  at  each  Bit- 
*g  may  be  from  m  xxx.  to  cxx.  It  is  seldom  irritating,  and  the  urgent 
desire  to  urinate  experienced  in  some  instances  after  its  use  will  quickly 
subside  It  is  on  the  whole  an  excellent  agent  for  extremely  sensitive 
urethras,  and  will  often  subdue  a  hyperasthetic  condition  when  i 

is  persisted  in. 

The  sulphate  of  copper  is  markedly  astringent,  much  more  so  than  the 
sulphate  of  thallin.  It  is  somewhat  more  irritating  than  this  latter  sub- 
stance, although  it  burns  but  little  in  weak  solutions.  It  is  also  more 


Fio.  21.— Posterior  Urethral  Instillation. 

suited  to  the  posterior  than  the  anterior  urethra.  When  the  posterior 
urethra  as  a  result  of  local  congestion  or  mild  catarrhal  inflammation  is 
found  to  be  hyperaemic  and  irritable,  such  a  condition  as  is  usually  bene- 
fited by  the  use  of  astringent  applications,  a  solution  of  sulphate  of  copper 
in  increasing  strength  may  be  employed  before  proceeding  to  the  use 
of  nitrate  of  silver  or  after  the  effect  of  thallin  has  been  exhausted. 
It  may  be  conveniently  kept  on  hand  in  a  ten-per-cent  glycerin  solution, 
which  will  not  precipitate,  and  the  desired  strength  can  be  obtained  by 
the  addition  of  water.  One  grain  to  the  ounce  will  be  found  very  mild, 
and  the  full  effect  is  generally  obtained  when  the  strength  has  been  in- 
creased up  to  five  or  ten  grains  to  the  ounce. 

The  nitrate  of  silver  is  probably  more  often  used  for  instillation  than 


CHRONIC   URETHRITIS.  49 

any  other  substance,  and  is  of  great  value.  It  is  stronger  than  any  of 
the  previous  applications,  and  even  when  employed  in  weak  solutions 
exerts  a  mild  caustic  influence,  which  is  a  desirable  property  for  granular 
conditions  of  the  mucous  membrane.  The  general  indications  for  the 
use  of  thallin  and  sulphate  of  copper  apply  to  nitrate  of  silver,  but  al- 
though it  is  more  irritating  than  either  of  the  others,  yet  it  is  sometimes 
better  tolerated  and  more  beneficial  even  to  sensitive  subjects.  Further- 
more it  has  a  wider  field  of  utility  than  either  of  them,  being  used  also 
in  the  anterior  urethra  with  good  effect,  on  account  of  its  bactericidal 
action.  In  that  form  of  chronic  urethritis  which  is  a  direct  prolongation 
of  recent  acute  trouble,  in  which  the  permanganate  of  potassium  has  been 
tried  and  found  ineffective,  or  when  this  latter  remedy  has  been  used  and 
under  its  influence  the  improvement  has  reached  a  stationary  period,  the 
substitution  of  a  mild  solution  of  silver  may  prove  of  decided  value. 
Again,  when  the  acute  process  of  a  recent  urethritis  has  found  its  way  to 
the  posterior  urethra  and  has  become  located  there,  its  use  will  sometimes 
assist  in  terminating  a  condition  which  had  promised  to  be  of  long  dura- 
tion. In  these  latter  cases,  when  well  tolerated,  it  should  be  used  in 
solutions  of  progressively  increasing  strength,  beginning  with  gr.  ss.  and 
running  up  to  about  gr.  x.  to  the  ounce. 

ProtargoL — This  substance,  which  has  already  been  referred  to  in  the 
consideration  of  acute  urethritis  (p.  33),  was  invented  by  Eichengriln, 
and  brought  to  the  public  notice  by  Neisser,  who,  together  with  others 
who  have  experimented  with  it,  have  more  particularly  called  attention 
to  its  value  in  acute  gonorrhceal  urethritis.  Later  reports  by  Kogues1 
and  Desnosa  have  given  an  account  of  their  experience  with  this  remedy 
in  the  treatment  of  chronic  urethritis,  the  results  of  which  Desnos  thinks 
show  that  it  has  greater  value  in  the  chronic  than  in  the  acute  condition. 
We  agree  with  him  that  it  is  inferior  to  permanganate  of  potassium  irri- 
gations for  gonorrhoea,  and- believe  that  its  place  as  a  topical  application 
to  the  urethra  belongs  among  the  preparations  used  for  posterior  urethral 
instillation. 

Protargol  is  a  proteid  silver  salt,  readily  soluble  in  water,  and  pos- 
sesses much  less  irritating  properties  than  the  nitrate  of  silver,  although 
in  solutions  stronger  than  three  to  four  per  cent  it  is  apt  to  excite  an 
intense  desire  to  urinate  when  deposited  in  the  posterior  urethra. 

A  concentrated  solution  of  protargol  makes  a  somewhat  viscid  and 
heavy  mixture,  and  therefore  should  be  used  in  a  syringe  with  not  too 
small  a  lumenand  with  a  capacity  of  from  3  iss.  to  3  ii.,  as  this  quantity 
is  the  amount  usually  injected  with  each  application. 

In  the  anterior  urethra  protargol  has  been  used  in  solutions  of  one- 
fourth  to  one  per  cent,  but  such  mild  solutions  are  of  no  value  in  the 

1  Ann.  des  Mai.  des  Org.  Genito-Urin.,  June,  1898.  2  Ibid.,  July,  1898. 

4 


50  VENEREAL  DISEASES. 

posterior  canal.  Desnos  recommends  it  in  five-  to  ten-per-cent  solutions, 
and  has  used  it  as  high  as  fifteen  per  cent  in  chronic  urethritis.  Its  best 
effect  is  to  be  obtained  from  strong  solutions  in  chronic  conditions.  We 
have  frequently  used  it  in  twenty-  and  twenty-five-per-cent  solutions,  and 
have  increased  it  as  high  as  forty  per  cent.  Such  strong  solutions  are 
best  prepared  before  each  application,  and  occasion  a  most  intense  desire 
to  urinate,  sometimes  irresistible,  and  may  produce  marked  symptoms  of 
irritation,  which  endure  for  one  or  two  days  in  many  cases,  while  in  some 
the  amount  of  irritation  does  not  seem  to  increase  relatively  with  the  in- 
creased strength  of  the  solutions.  Generally  speaking,  when  such  strong 
solutions  are  well  borne,  they  are  likely  to  produce  good  results. 

The  subsequent  applications  should  be  at  intervals  of  about  forty -eight 
hours,  or  even  longer,  according  to  the  irritation  produced,  which  should 
be  allowed  to  subside  before  repeating  the  treatment. 

When  improvement  is  not  noted  after  a  reasonable  period  under  the 
local  use  of  this  remedy  in  increasing  strength,  it  should  be  abandoned. 

In  that  form  of  chronic  posterior  urethritis  following  closely  upon 
gonorrhoea,  its  use  is  sometimes  attended  with  markedly  good  results, 
either  in  connection  with  the  permanganate  irrigation  of  the  anterior 
urethra  or  after  the  latter  remedy  has  been  discontinued.  In  this  condi- 
tion it  is  well  to  start  with  a  solution  of  from  three  to  five  per  cent,  and 
gradually  increase  as  improvement  is  noted.  In  other  cases  of  chronic 
urethritis,  of  much  longer  standing,  protargol  may  prove  an  effective 
remedy  when  the  trouble  is  one  that  involves  the  mucosa  alone,  and  in 
some  instances  success  will  attend  its  use  when  other  agents  have  failed. 
It  may  also  be  employed  when  the  more  deep-seated  tissues  or  glandular 
structures  are  affected,  as  an  adjuvant  to  the  other  treatment  adopted. 
In  the  treatment  of  stricture  of  the  urethra  by  the  passage  of  sounds,  it 
may  be  used  as  a  topical  application  to  the  inflamed  mucosa,  directly 
behind  the  stricture  or  more  properly  to  a  posterior  urethral  catarrh, 
which  often  coexists  with  stricture  of  the  anterior  canal ;  and  again  in 
chronic  prostatitis,  while  it  does  not  reach  the  substance  of  the  gland,  it 
may  be  beneficially  applied  to  the  surface  inflammation,  while  the  deeper 
structures  are  attacked  by  other  means. 

The  use  of  protargol  in  weaker  solutions,  one-fourth  to  one  per  cent, 
for  urethro-vesical  lavage  or  irrigation  has  also  been  recommended,  not- 
ably when  the  discharge  is  abundant  or  the  urine  richly  purulent.  This 
may  be  conducted  in  the  same  manner  as  employed  with  the  permanga- 
nate of  potassium,  and  in  some  cases  with  beneficial  result. 

Ichthyol.—This  preparation  is  lauded  highly  by  some  observers  for  its 

>thing  and  antiphlogistic  properties  in  the  urethra.     Of  its  use  in  acute 

Jthritis  we  have  nothing  to  say.     Jn  the  chronic  form  of  this  malady  it 

b  be  recommended  for  the  anterior  urethra;  its  results  are  not  equal 

those  obtained  from  the  other  remedies  already  mentioned.     In  the 


CHRONIC   URETHRITIS.  51 

posterior  urethra  in  some  cases  of  a  subacute  and  chronic  character  good 
results  have  been  noted  after  other  means  had  failed,  and  it  is  on  this 
account  that  it  is  considered  worthy  of  being  retained  in  the  list  of  im- 
portant topical  applications.  We  find  that  in  cases  in  which  its  favorable 
effect  is  produced,  the  strength  of  the  solution  can  be  beneficially  increased 
beyond  what  has  been  usually  recommended,  up  to  fifteen  or  even  twenty 
per  cent.  It  is  well,  however,  to  commence  with  a  solution  of  very  mild 
strength,  viz.,  2  to  3  per  cent. 

TOPICAL  APPLICATIONS  BY  MEANS  OP  THE  ENDOSCOPE. 

Even  those  who  are  ardent  advocates  of  the  general  employment  of 
urethroscopy  do  not  urge  its  use  in  the  posterior  urethra  where  its  appli- 
cation is  often  painful  and  productive  of  hemorrhage.  With  the  Ober- 


FIG.  22.— Straight  Tube  for  Anterior  Urethroscopy.    (OberlSnder-Nitze.) 

lander-Nitze  urethroscope  (see  Fig.  14,  page  40)  the  endoscopic  tube  is  in- 
troduced by  means  of  a  jointed  obturator  (Figs.  22  and  23).  Those  who  are 
skilled  in  the  employment  of  this  method  in  the  posterior  urethra  in  favor- 
able cases  are  able  to  make  ocular  inspection  of  the  prostatic  and  ejaculatory 
ducts,  the  caput  gallinaginis,  and  colliculus  seminalis.  It  is  not  denied  that 
the  use  of  the  endoscopic  tube  in  the  posterior  urethra,  on  account  of  the 
irritation  produced,  is  contraindicated  in  acute  or  subacute  posterior  ure- 
thritis  in  tuberculous  cases  and  in  hypertrophy  of  the  prostate,  yet  it  is 
claimed  that  in  sexual  neuroses  and  in  chronic  posterior  urethritis  it  will 
often  be  found  useful. '  Even  admitting  the  truth  of  this  claim,  there  is 


FIG.  23.— Jointed  Obturator  for  Posterior  Urethroscopy. 

nothing  to  show  that  the  results  obtained  are  in  any  way  superior  to 
those  following  the  simpler  and  more  practical  methods  already  detailed 
for  deep  urethral  medication. 

The  therapeutic  application  of  urethroscopy  to  the  anterior  urethra  is 
much  more  practical  and  sometimes  decidedly  serviceable.     It  is  not  to 

1U  Practical  Urethroscopy,"  Wossidlo,  New  York  Medical  Eecord,  September, 
1895. 


52 


VENEREAL  DISEASES. 


be  recommended  as  a  routine  method.     The  different  endoscopic  tubes 
and  apparatus  have  already  been  referred  to  in  speaking  of  the  diagnos 


F».  24.— Anterior  Urethra!  Polypus. 

chronic  urethritis  (see  page  39) .  Any  one  of  these  instruments  may  be  em- 
ployed for  the  purpose  of  obtaining  an  ocular  view  of  a  localized  lesion  in 
the  anterior  urethra,  and  of  permitting  a  direct  application  to  the  surface 
of  a  diseased  area  for  the  removal  of  granulations,  papillomata,  or  polypi. 
For  the  latter  purpose  may  be  employed  a  small  wire  snare  (Fig.  25), 


G.TIEMANN&.CO. 
FIG.  26.— Wire  Urethral  Curette. 


the  urethral  forceps,  or  a  small  wire  curette  (Fig.  26).  The  topical 
applications  may  be  made  by  means  of  a  cotton  swab  twisted  on  an 
applicator.  For  this  purpose  the  nitrate  of  silver  is  commonly  used  in  a 


CHRONIC   URETHRITIS. 


53 


solution  of  from  gr.  i.  to  gr.  xxv.  to  the  ounce.  If  the  visual  inspection 
is  able  to  detect  the  presence  of  a  small  abscess  in  one  of  the  follicles  of 
the  urethra,  it  may  be  incised  through  the 
endoscopic  tube  by  means  of  a  properly 
constructed  knife,  such  as  that  of  Koll- 
man  (Fig.  27),  and  the  sac  of  the  follicle 
injected  by  means  of  a  small  intra-urethral 
syringe  or  pipette  (Fig.  28  and  Fig.  44, 
page  70).  Such  an  abscess  cavity  may  be 
washed  out  with  a  mild  antiseptic  solution, 
but  it  is  best  treated  by  the  introduction  of 
a  few  drops  of  the  ethereal  solution  of  per- 
oxide of  hydrogen,  which  will  cause  a  rapid 


disintegration  of  the  inflammatory  tissue  and  complete  closure  of  the 
cavity  by  contraction  of  the  follicular  sac. 

In  concluding  this  subject  we  must  repeat  that  this  method  should  be 
restricted  within  the  lines  of  special  indications,  and  that  its  general 
usage  is  to  be  discouraged.  Such  a  practice  as  the  use  of  daily  endo- 
scopic applications  to  the  urethra  is  not  only  liable  to  produce  undesirable 
results  upon  the  urethra,  but  must  gain  for  the  physician  the  far  from 
enviable  reputation  of  being  a  potterer. 


CHAPTER   III. 

BALAKITIS     AND     POSTHITIS—  HERPES      PROGENITALIS— 
VENEREAL  WARTS. 

BALANITIS  signifies  inflammation  of  the  surface  of  the  glans  penis, 
posthitis  inflammation  of  the  prepuce,  generally  of  its  internal  mucous 
lining.  As  these  two  conditions  often  coexist,  the  term  balano-posthitis 
is  employed.  A  long  foreskin  with  small  orifice  predisposes  to  this  dis- 
order, and  the  irritation  due  to  retained  smegma,  urethral  discharge,  or 
other  irritating  fluid  acts  as  an  exciting  cause.  This  condition  is  a 
common  complication  of  gonorrhoea. 

In  a  mild  form  it  amounts  only  to  a  bright  redness  and  moisture  of  the 
mucous  membrane,  surrounding  the  glans  and  foreskin  with  a  certain 
amount  of  creamy  secretion  of  sharp,  offensive  odor,  and  accompanied  by 
a  constant  itching  or  burning  of  the  parts.  In  a  more  advanced  form  the 
mucous  surface  may  become  covered  with  excoriations.  The  whole  sub- 
stance of  the  prepuce  may  be  swollen  and  reddened,  even  sufficiently 
inflamed  if  the  preputial  orifice  be  narrow  to  occasion  inflammatory 
phimosis.  The  excoriations  result  from  the  loss  of  epithelium  in  irregular 
patches,  but  when  the  irritation  persists  they  go  on  to  form  ulcerations 
superficial  in  character,  more  rarely  deep,  simulating  closely  the  appear- 
ance of  chancroids.  An  irregular  form  of  balanitis  occurs,  called  '  "  cir- 
cinate,"  which  appears  in  concentric  patches  resembling  ringworm  of  the 
skin,  said  to  be  due  to  a  special  organism  and  of  venereal  origin. 

Chronic  balano-posthitis  occurs  in  men  past  the  middle  age,  generally 
in  those  with  a  tight  and  pendulous  foreskin.  The  inflammation  is  mild 
in  character,  and  as  it  extends  over  a  long  period  produces  a  great  deal 
of  thickening  of  the  mucous  surface  of  the  prepuce,  which,  when  re- 
tracted, is  found  to  be  covered  with  granular  prominences  or  superficial 
excoriations.  Sometimes  the  prepuce  is  so  much  thickened  around  the 
orifice  that  retraction  is  impossible.  A  continuation  of  this  process  results 
in  contraction  of  the  infiltrated  layer  of  epithelial  and  submucous  tissue 
that  has  been  deposited  and  a  corresponding  decrease  in  the  normal  size 
of  the  glans  penis. 

The  complications  of  balano-posthitis  are   phimosis,   paraphimosis, 

etations,  lymphangitis,  inguinal  adenitis,  gangrene.     Phimosis  is  the 

^result  of  inflammatory  swelling.     Paraphimosis  is  due  to  thicken- 


iR™0IVVenereal  Disea8es-"    Berdall  and  Battaile:  La  M4decine  moderns, 
IM,  and  Annal.  des  Malad.  des  Organes  gfo.-urin.,  vol.  viii.,  1890. 


BALANITIS  AND   POSTHITIS.  55 

ing  of  a  retracted  foreskin.  Lymphangitis  when  present  is  similar  to 
that  which  occurs  with  chancroids  of  the  penis  (see  p.  192).  Inguinal 
adenitis  sometimes  accompanies  lymphangitis  as  a  complication  of  balani- 
tis, and  resembles  the  same  condition  occurring  in  connection  with  chan- 
croids. Vegetations  or  pointed  condylomata  sometimes  complicate  a 
balano-posthitis  as  a  result  of  the  same  causes  that  produced  the  latter 
trouble.  Gangrene  of  the  constricted  prepuce  may  result  from  excessive 
swelling  of  the  parts,  the  sloughing  of  the  tissue  included  in  the  con- 
stricted area  entailing  ultimate  deformity  due  to  cicatricial  contraction. 
This  complication  is  more  apt  to  occur  in  debilitated  and  cachectic  in- 
dividuals. 

The  diagnosis  of  balanitis  is  simple  in  most  cases,  but  it  may  be  con- 
founded with  herpes,  chancroid,  or  gonorrhoea.  When  the  inflammation 
runs  high,  and  perhaps  exulceration  exists  upon  the  foreskin,  it  is  diffi- 
cult to  distinguish  balanitis  from  herpes.  In  the  early  stage  the  outline 
of  herpetic  vesicles  may  be  recognized. 

Chancroid  is  more  apt  to  be  confounded  with  severe  balanitis,  com- 
plicated by  deep  ulcerations.  The  course  of  the  inflammation  is  much 
more  severe  and  rapid  in  chancroid.  Lymphangitis  and  adenitis  are 
quite  common,  while  in  simple  balano-posthitis  they  are  less  apt  to  be 
present,  except  in  poorly  nourished  and  debilitated  individuals. 

In  subpreputial  chancre  or  chancroid,  when  the  foreskin  does  not  pull 
back,  the  diagnosis  remains  doubtful  until  the  preputial  cavity  can  be  in- 
spected or  other  signs  clear  up  the  doubt.  When  there  is  a  copious  flow  of 
pus,  if  there  be  phimosis,  balanitis  may  be  mistaken  for  acute  gonorrhoea. 
This  question  is  settled  by  the  examination  of  the  discharge  for  the 
gonococcus,  and  by  determining  whether  or  not  the  flow  exudes  from  the 
meatus  or  is  derived  from  the  cavity  of  the  prepuce. 

Treatment. — When  the  prepuce  can  be  retracted,  mild  balanitis  may 
be  speedily  relieved  by  the  exercise  of  cleanliness  and  the  use  of  a  mild 
disinfectant  or  astringent  lotion.  For  this  purpose  may  be  used  the 
following : 

]$  Acid,  boric.,        .         .        .         .         .        ,'      .        .         •    3  *»• 

Zinc,  sulphocarbolat,         .        .        .        ...        .  gr.  i. 

Aquse, I  iv. 

1$  Zinc,  sulphat., 

Thymol., aa  gr.  i. 

Acid,  boric., 3  i. 

Spirit,  lavartfl.  comp., 3  ij. 

Aquae, q.s.  ad   §  iv. 

IJ  Vini  aromatic., 3  iv. 

Aquse,          .         .         .         .         • §  i- 

M. 

1$  Liquor  plumbi  subacetatis, 3  !• 

Aquae,         . §  iv. 


gg  VENEREAL  DISEASES. 

A  piece  of  absorbent  cotton  or  a  strip  of  thin  old  cotton  cloth,  moist- 
ened in  one  of  the  above  lotions,  is  laid  around  the  glans  and  the  prepuce 
pulled  forward  to  its  natural  position.  This  prevents  friction  and  absorbs 
the  irritating  discharge.  Dressings  should  be  repeated  several  times  a 
day.  Sometimes  a  dry  dressing  acts  better  than  a  moist  one,  especially 
when  erosions  or  ulcerations  exist.  Under  these  circumstances  the  dis- 
charge should  be  frequently  removed  and  the  glans  and  prepuce  carefully 
washed  with  a  mild  disinfectant  solution  (corrosive  sublimate  1  :  6,000  or 
8,000)  after  which  the  parts  should  be  dried  with  absorbent  cotton  and  the 
surface  dusted  with  bismuth,  perhaps  containing  a  little  boric  acid  or  calo- 
mel, or  with  eudoxin.  The  combination  known  as  dolomol  tar  we  have  found 
a  useful  and  unirritating  dusting-powder.  In  chronic  cases  and  when  the 
ulcerations  persist  in  spite  of  the  soothing  form  of  treatment,  the  applica- 
tion of  a  solution  of  nitrate  of  silver,  gr.  x.-xxx.  to  the  ounce,  by  means 
of  a  camel's-hair  brush  may  assist  in  bringing  about  a  more  rapid  cure. 
When  the  prepuce  cannot  be  retracted,  its  cul-de-sac  must  be  cleansed 
thoroughly  with  hot  water,  and  one  of  the  above  lotions  by  means  of  a 
duck-bill  syringe  (Fig.  11,  page  36).  This  should  be  done  frequently 
during  the  day,  as  often  as  the  discharge  reaccumulates.  If  the  parts  are 
generally  swollen,  a  wet  dressing  of  Thiersch's  or  mild  sublimate  solution 
should  be  employed  in  addition  to  the  other  measures.  If  by  the  adoption 
of  such  means  improvement  is  deferred,  or  if  the  inflammation  is  so  in- 
tense that  sloughing  of  the  prepuce  be  threatened,  it  is  better  to  relieve 
tension  by  slitting  up  the  dorsum  of  the  foreskin.  If  upon  exposure  of 
the  region  behind  the  glans  chancroid  is  discovered,  its  treatment  should 
be  conducted  in  accordance  with  the  instructions  laid  down  in  the  section 
on  chancroidal  phimosis  (p.  186).  In  all  chronic  cases  of  balanitis  with 
phimosis  and  thickening  of  the  mucous  membrane  circumcision  affords 
proper  means  of  relief,  and  should  be  resorted  to.  Lotions  and  astringent 
injections  in  these  cases  afford  little  relief,  as  relapses  are  liable  to  recur 
continually. 

HERPES  PROGENITALIS. 

Herpetic  vesicles,  single  or  multiple,  appear  upon  the  mucous  mem- 
brane covering  the  glans  and  prepuce  and  upon  the  cutaneous  envelope 
of  the  penis.  They  may  be  located  in  the  sulcus,  behind  the  corona,  in 
the  folds  of  the  frenum  on  either  side,  around  or  inside  the  meatus,  or 
on  any  portion  of  the  integument.  When  occurring  upon  the  skin  the 
vesicles  dry  down  and  form  scabs,  but  when  situated  upon  the  mucous 
lining  they  run  a  different  course  owing  to  the  rupture  of  the  vesicle, 
which  takes  place  early,  leaving  a  more  or  less  superficial  exulceration. 

the  case  of  a  single  vesicle  this  is  irregularly  round,  but  when  several 
vesicles  lie  close  together  they  may  become  fused  into  a  single  patch  of 


HERPES   PROGENITALIS.  57 

irregular  outline.  The  symptoms  attending  this  lesion  are  burning  or 
itching  of  the  surface  implicated,  and  a  certain  amount  of  watery  secre- 
tion, which,  when  allowed  to  collect,  becomes  purulent.  Subpreputial 
herpes,  after  the  vesicles  break,  may  run  on  into  balano-posthitis  if  the 
secretion  be  allowed  to  accumulate.  When  the  ulcerations  become  un- 
usually deep  as  the  result  of  neglect  of  treatment  or  constitutional  debil- 
ity, and  are  accompanied  by  inguinal  adenitis,  the  sores  may  be  con- 
founded with  chancroidal  ulceration.  In  reaching  a  diagnosis  it  should 
be  remembered  that  the  herpetic  condition  starts  in  vesicles,  generally  in 
clusters  which  precede  the  appearance  of  ulceration,  and  that  bubo  is 
uncommon.  Differential  diagnosis  is  sometimes  difficult,  but  a  decision 
may  be  promptly  and  surely  reached  by  auto-inoculation.  The  pus  of 
ulcerated  herpes  will  not  produce  the  typical  ulcer  which  surely  follows 
the  auto-inoculation  of  chancroidal  pus.  The  duration  of  herpes  when 
uncomplicated  is  from  three  or  four  days  to  a  fortnight. 

The  causes  of  herpes  are  local  irritation  and  diathetic  predisposition. 
Uncleanliness,  the  decomposition  of  sebaceous  material,  especially  when 
the  prepuce  is  long  and  contracted,  and  the  friction  of  intercourse  may  be 
cited.  Full-blooded,  gouty,  rheumatic,  and  neurotic  individuals  seem  to 
possess  a  predisposition  to  the  affection.  If,  as  has  been  held  by  one  or 
two  observers,  it  is  of  special  microbic  origin,  sufficient  evidence  has  not 
been  produced  to  sustain  the  claim.  Sometimes  herpes  progenitalis  is 
attended  by  rather  pronounced  neuralgic  pain — a  feature  which  may  bet 
marked  in  any  kind  of  herpes,  reaching  its  highest  expression  in  herpes 
zoster.  This  rather  exceptional  accompanying  symptom  has  led  a  few 
authors  to  the  extremity  of  erecting  a  new  sub-variety  of  herpes,  which 
they  call  neuralgic. 

Treatment. — For  cutaneous  herpes  prevent  the  vesicles  from  breaking 
by  covering  the  patch  with  collodion,  and  keep  it  covered  until  it  is  well. 
If  the  vesicles  break,  dust  them  with  bismuth  or  eudoxin.  On  the  mu- 
cous surface  touch  the  vesicles  twice  daily  with  eucalyptol  and  dust  with 
bismuth  or  eudoxin  when  they  break.  After  excoriations  occur  the  treat- 
ment is  generally  the  same  as  for  balanitis,  requiring  that  the  irritating 
discharge  should  be  removed  and  the  parts  cleansed  and  maintained  in  this 
condition  by  suitable  disinfectant  lotions.  As  indicated  in  the  previous 
section  on  balanitis,  after  using  the  lotion  the  parts  should  be  thoroughly 
dried  and  a  mild  dusting-powder  applied — bismuth,  zinc,  starch,  and  ly- 
copodium.  The  dolomel  and  tar  or  eudoxin  will  be  found  especially  effi- 
cacious. Eudoxin  is  the  bismuth  salt  of  nosophen,  the  latter  being  a 
compound  rich  in  iodine  and  an  iodoform  substitute.  Underlying  con- 
stitutional conditions  should  be  attended  to.  In  chronic  and  relapsing 
herpes,  in  cases  accompanied  by  sharp  neuralgic  pains,  and  in  those 
showing  a  tendency  to  persistent  ulceration,  it  is  necessary  to  alter  the 
surface  by  a  caustic,  for  which  purpose  may  be  employed  carbolic  acid, 


gg  VENEREAL  DISEASES. 

a  ten-per-cent  solution  of  nitrate  of  silver,  or  antiseptic  pyrozgne. 
When  a  long,  tight  prepuce  is  the  predisposing  cause,  circumcision  is 
the  natural  remedy. 

VENEREAL  WARTS. 

Vegetations,  condylomata,  or  venereal  warts,  as  they  are  commonly 
called,  spring  up  readily  in  both  sexes  about  the  genitals  if  acrid  and 
irritating  discharges  be  retained  until  they  have  had  time  to  decompose. 
Pathologically  they  consist  of  highly  vascular  papillary  outgrowths,  com- 
posed of  an  increase  of  the  epithelial  and  connective  tissue.  They  are 
not  necessarily  of  venereal  origin,  but  are  common  under  a  tight  prepuce 
in  connection  with  gonorrhoaa,  and  often  found  complicating  balanitis 
when  there  is  no  urethral  inflammation.  Those  that  occur  upon  the 
mucous  membrane  are  soft  and  yielding  in  character ;  upon  the  integu- 
ment they  are  harder.  When  dry  they  resemble  ordinary  seed  warts, 
and  are  composed  of  pointed  epithelial  prominences  which  grow  up  into 
a  raspberry-like  mass,  varying  from  the  size  of  a  pinhead  to  that  of  a 
hickory  nut.  They  may  spread  out  as  a  dry  velvety  growth  over  a  large 
surface.  The  soft  warts  are  commonly  situated  behind  the  corona  glandis 
on  either  side  of  the  frenum,  but  may  be  encountered  on  any  portion  of 
the  mucous  surface  of  the  prepuce.  They  are  sometimes  found  in  the 
mouth  of  and  deep  in  the  urethra,  and  are  distributed  also  over  the  scrotum 
and  frequently  around  the  anus.  They  may  be  scattered  in  irregular 
collections  in  one  or  more  of  these  sites,  or  may  be  so  abundantly  gathered 
upon  the  glans  penis  as  completely  to  bury  it,  giving  a  cauliflower-like 
appearance,  with  the  glans  almost  hidden  from  view ;  or  if  the  prepuce 
be  long,  the  extensive  outgrowth  may  emerge  through  the  orifice,  or,  on 
account  of  a  tight  phimosis  and  consequent  subpreputial  pressure,  may 
produce  gangrene  and  perforation  of  the  prepuce. 

The  inflammation  due  to  these  excrescences  and  their  irritating  dis- 
charge may  result  in  a  balano  posthitis  and  inflammatory  phimosis. 

Paraphimosis  may  also  come  on  during  a  retraction  of  the  prepuce  on 
account  of  the  hyperplastic  inflammatory  condition  of  the  tissues  due  to 
their  presence. 

The  contagiousness  of  venereal  warts  has  been  maintained  by  some 
writers,  but  this  question  is  still  unsettled. 

The  diagnosis  of  these  growths  is  self-evident.  They  should  not  be 
confounded  with  "condylomata  late,"  which  are  of  specific  origin  and 
generally  accompanied  by  a  clear  syphilitic  history.  Such  an  error  can 
be  made  only  when  the  vegetations  or  warts  have  existed  for  a  long  time 

1  have  undergone  changes  which  have  resulted  in  their  becoming  more 

5  with  pronounced  flattening  of  the  surfaces.     Epithelioma  at  the 

nmng  of  its  course  may  be  mistaken  for  condylomata.    The  former  ap- 

J  late  in  life  and  is  accompanied  by  infiltration  of  the  adjacent  tissues 


VENEREAL  WARTS.  59 

and  enlargement  of  the  nearest  chain  of  glands.  In  a  case  of  doubt,  in 
which  the  suspicion  has  been  raised,  microscopic  examination  will  decide. 

Treatment. — The  prophylaxis  against  these  warty  excrescences  is 
cleanliness,  especially  in  the  event  of  balanitis  or  gonorrhoea.  When 
warts  are  encountered  in  cases  in  which  the  foreskin  can  be  retracted,  they 
may  be  removed  with  scissors  and  their  bases  cauterized  with  nitric 
acid  or  caustic  pyrozone,  having  previously  anaesthetized  the  surface 
with  cocaine.  When  the  growths  cover  an  extensive  area  they  may  be 
thoroughly  scraped  away  by  means  of  a  sharp  curette  and  the  denuded 
surface  cauterized  with  acid  and  treated  with  a  dry  dusting-powder  com- 
posed of  calomel,  oxide  of  zinc  and  bismuth,  or  eudoxin,  the  bismuth  salt 
of  nosophen,  an  iodine  compound  and  an  iodoform  substitute. 

A  most  satisfactory  way  to  treat  these  warts  is  to  apply — 

]$  Acid,  salicylic., gr.  L 

Acid,  acetic.,       .         -.        .        .         .         .         .         .         .    §  i. 

This  combination  forms  a  curd-like  mixture  which  generally  will  remove 
warts  of  all  sizes  upon  the  foreskin  and  prepuce,  leaving  a  smooth  surface 
within  twelve  or  twenty -four  hours.  In  using  this  preparation  a  suffi- 
cient quantity  of  the  dregs  of  the  mixture  should  be  deposited  upon  the 
growths  to  cover  their  entire  surface,  and  be  allowed  to  dry.  One  appli- 
cation is  generally  sufficient. 

When  vegetations  occur  within  a  phimosed  foreskin,  it  may  be  neces- 
sary to  slit  or  cut  away  the  latter- 

Phimosis,  Paraphimosis,  Circumcision. — Phimosis  is  said  to  exist  when 
the  orifice  of  the  prepuce  is  too  small  to  allow  the  glans  penis  to  be  un- 
covered. It  may  occur  congenitally,  but  is  also  acquired  as  a  complica- 
tion during  an  attack  of  balano-posthitis,  either  alone  or  in  combination 
with  the  presence  of  herpes,  vegetations,  or  chancroid. 

This  condition  exists  in  various  degrees  as  a  congenital  formation, 
producing  a  contracted  orifice,  which  may  simply  prevent  retraction  of 
the  foreskin  or  may  be  so  tight  as  to  impede  the  flow  of  urine.  Such  an 
extreme  condition  will  naturally  favor  the  occurrence  of  balanitis,  and 
interfere  with  the  proper  treatment  of  the  morbid  conditions  which  attack 
the  interior  of  the  prepuce. 

Inflammatory  phimosis  is  a  transient  trouble  due  to  inflammation  of 
the  prepuce.  It  may  leave  behind  a  true  phimosis  as  a  result  of  chronic 
thickening.  The  treatment  of  inflammatory  phimosis  consists  in  treating 
the  cause  which  underlies  it;  in  addition  evaporating  lotions  in  the  form 
of  wet  dressing  may  be  applied,  while  the  cavity  of  the  prepuce  is  kept 
continually  washed  with  an  antiseptic  solution  composed  of  carbolic  acid, 
1:50,  or  corrosive  sublimate,  1  :  5,000.  It  is  better  not  to  incise  an 
inflammatory  phimosis  unless  the  condition  inside  the  prepuce  demands 
it.  When  such  is  the  case  the  operation  should  be  performed  by  making 


60 


VENEREAL  DISEASES. 


two  lateral  incisions,  and  completing  the  circumcision  when  the  inflam- 
matory condition  and  local  lesions  have  yielded  to  treatment. 


FIG.  29. 


Paraphimosis  is  the  condition  which  exists  when  the  prepuce  gets 
behind  the  corona  glandis  and  cannot  be  replaced.  Occurring  with  gonor- 
rhoea it  is  caused  by  oedema  of  the  retracted  foreskin.  Such  inflamma- 
tory paraphimosis  may  depend 
also  upon  balanitis,  herpes, 
chancroid,  or  chancre.  The 
glans  penis  in  paraphimosis  is 
swollen  and  livid.  When  seen 
early  there  may  be  little  in- 
flammation of  the  glans  or  pre- 
puce, but  when  the  condition 
continues  and  is  unrelieved, 
inflammation  may  reach  a  high 
degree,  oedema  of  the  prepuce 
becomes  very  extensive,  the  con- 
stricting portion  behind  the 
corona  appears  like  a  cartilagi- 
nous ring,  and  the  glans  penis 

/%-..  may    even    become    gangrenous 

W&  M         f   '  ,  , . 

from  strangulation. 

Sometimes,     although    the 
foreskin  is  not  long   enough  to 
cover  the  glans,  oedema  may  oc- 
cur, giving  the  same  appearance 
FIG.  30.  as  in  the  case  of  paraphimosis 

with  contracted  and  long  pre- 
puce. Under  these  circumstances  the  deeper  parts  are  not  strangulated, 
and  there  is  no  occasion  to  attempt  reduction. 


VENEREAL,   WARTS. 


61 


The  treatment  of  paraphimosis  varies  with  the  presence  or  absence  of 
strangulation.  When  there  is  no  strangulation,  the  indication  is  to 
endeavor  to  allay  the  inflammation  by  the  use  of  wet  dressings  or  fomen- 
tations. In  some  mild  cases  the  application  of  a  few  coats  of  contractile 


FIG.  31. 

collodion  over  the  smooth  mucous  membrane  will  control  the  tendency  to 
increasing  oedema  and  may  cause  its  disappearance.  Should  positive 
strangulation  of  the  penis  occur,  as  evidenced  by  the  bluish-black  color  of 
the  glans,  which  becomes  turgid  and  swollen,  cold  and  devoid  of  sensibility, 
reduction  of  the  strangulation  is  imperative.  This  may  be  done  in  several 
ways.  One  way  is  to  en- 


circle  the  penis  with  one 
hand  (Figs.  29  and  30),  or 
with  the  thumb  and  index 
finger  of  one  hand,  using 
the  other  one  to  knead  and 
compress  the  glans  and 
push  it  back  through  the 
constricted  ring  of  the 
prepuce.  Another  is  to 
grasp  the  penis  behind 
the  constricted  portion  be- 
tween the  index  and  middle  fingers  of  both  hands,  making  pressure  with 
the  thumbs  on  either  side  of  the  glans  and  at  the  same  time  pulling 
the  strictured  prepuce  forward,  the  purpose  being  to  make  the  glans  as 
small  as  possible  and  to  draw  the  constriction  over  it  rather  than  to  push 
the  glans  through  the  stricture  (Fig.  31).  Still  another  method  is  to  com- 
press the  swollen  glans  by  means  of  a  one-half-inch  muslin  or  rubber 


FIG.  32. 


62 


VENEREAL  DISEASES. 


bandage,  applying  it  from  apex  to  base,  and  then  endeavor  to  retract  the 
prepuce  forward  with  the  bandage  in  place  by  one  of  the  manipulations, 
or  to  remove  the  bandage  and  immediately  attempt  reduction  before  the 
engorgement  has  had  time  to  return  to  the  same  extent  (Fig.  32).  Finally 
by  means  of  the  introduction  of  hair-pins,  one  on  either  side  of  the  glans, 
beneath  the  constriction,  to  act  as  directors,  success  may  be  accomplished 
when  the  other  methods  have  failed  (Fig.  33).  When  the  prolonged  and 
careful  attempts  at  reduction  fail,  the  stricture  behind  must  be  divided 


FIG.  33. 


with  the  knife.  To  accomplish  this  a  blunt  tenotomy  knife  is  introduced 
on  its  flat  surface  beneath  the  stricture,  and  is  made  to  cut  outward,  or 
the  incision  may  be  made  directly  down  upon  the  sheath  of  the  penis, 
ometimes  the  inflammatory  infiltration  of  the  tissues  necessitates  the 
division  of  the  stricture  at  several  points. 

Circumcision.— To  expose  the  glans  penis  it  is  sufficient  to  make  one 

incision  upon  the  dorsum  of  the  prepuce,  including  both  layers,  from 

3  to  the  base  of  tho  corona,  and  after  trimming  off  the  corners 

the  two  layers  on  either  side.     When  the  prepuce  is  very  tight, 

|d  director  may  be  passed  from  the  orifice  to  the  corona,  in  the 

A  short,  pointed  bistoury  is  then  run  along  the  groove, 

ich  transfixes  the  skin  and  incises  the  entire  prepuce.     This  operation 


VENEREAL.  WARTS. 


63 


leaves  two  clumsy  dog's  ear  flaps,  but  is  much  simpler  than  complete  cir- 
cumcision. Taylor  strongly  recommends  instead  of  the  dorsal  incision 
that  two  lateral  cuts  be  made,  and  contends  that  the  dorsal  incision  is 


FIG.  34.— Authors'  Phimosis  Clamp. 

unsatisfactory  in  that  it  does  not  always  produce  the  desired  relief  and 
renders  the  parts  less  accessible  than  by  the  lateral  cuts. 

Circumcision  proper  is  a  simple  operation  which  is  performed  for  the 
purpose  of  removing  the  orifice  of  a  tight  prepuce  and  all  redundant  tis- 
sue. The  operation  is  as  follows :  Wash  the  outside  of  the  foreskin,  and, 


FIG.  35.— Circumcision  I.    Showing  aniline  line  to  mark  incision. 

if  possible,  the  inside  as  well.  In  children  general  anaesthesia  should 
be  employed.  In  adults  local  cocaine  or  eucaine  anaesthesia  suffices  un- 
less the  operation  is  to  be  complicated  and  prolonged.  The  prepuce  is 
caught  at  its  orifice  and  drawn  forward,  not  rolled  upon  itself,  and  a 
clamp  applied  in  an  oblique  direction — that  is  to  say,  the  general  direc- 


64 


VENEREAL  DISEASES. 


turn  of  the  corona-at  the  point  corresponding  to  a  line  previously  drawn 
on  the  integument  parallel  to  and  somewhat  in  front  of  the  corona,  while 
the  foreskin  was  in  its  normal  position.  The  cavity  of  the  prepuce 
should  be  injected  full  of  an  eight-  or  ten-per-cent  solution  of  cocaine, 
which  should  be  retained  for  at  least  five  minutes.  The  line  of  the  mcis 
ion  through  the  integument  can  be  completely  anaesthetized  by  infiltration 
with  cocaine.  For  this  purpose  a  two-per-cent  solution  is  used,  after 
which,  if  one  wishes  a  neat  operation,  the  base  of  the  penis  may  be  con- 
stricted with  a  rubber  tube  or  catheter,  the  ends  of  which  are  fastened  in 
place  by  a  bit  of  tape  or  a  haemostatic  forceps.  As  the  relation  of  the 


FIG.  36,— Circumcision  II.    Showing  clamp  applied  to  foreskin. 

parts  is  somewhat  disturbed  by  these  preliminary  steps,  it  is  a  good  plan 
to  mark  the  line  of  the  incision  upon  the  integument  with  an  aniline 
pencil  before  doing  anything  else  (Fig.  35).  The  phimosis  clamp  is  now 
applied  and  with  a  sharp  bistoury  or  scissors  the  prepuce  is  cut  away  be- 
yond the  blades  (Fig.  36).  After  removal  of  the  forceps  retraction  of  the 
integument  occurs,  and  the  mucous  membrane  is  left,  covering  the  glans 
(Fig.  37).  This  should  be  slit  down  upon  the  dorsum  or  laterally  (Fig.  38) 
about  one-quarter  inch  from  the  corona,  peeled  or  dissected  from  the  glans 
if  there  be  adhesions,  and  trimmed  away  on  either  side,  leaving  about  one- 
fourth  of  an  inch  to  hold  the  sutures.  As  many  bleeding  points  as  can 
be  controlled  by  torsion  should  be  treated  in  this  way,  and  ligatures  ap- 
plied only  where  necessary.  Blood  clots  should  be  scratched  away  with 
the  nail  and  any  little  oozing  vessel  twisted.  If  in  spite  of  the  oval  opening 
of  the  oblique  incision  the  newly  made  orifice  appears  too  tight,  a  liber- 


VENEREAL   WARTS. 


65 


ating  incision  should  be  made  down  the  back  of  the  penis  for  one-fourth 
of  an  inch.     The  mucous  membrane  must  be  liberated  so  as  to  leave  the 


FIG.  37.— Circumcision  III.    After  removal  of  clamp. 

entire  corona  clean.  The  best  material  for  ligature  is  rather  coarse 
horse-hair.  Catgut  is  not  suitable.  It  makes  a  large  suture  hole,  and  is 
liable  to  give  way  during  erection.  It  is  better  than  silk  because  it  does 


.  38.— Circumcision  IV.   Showing  mucous  membrane  after  lateral  incision  and  before  it  is  trimmed. 

5 


66  VENEREAL  DISEASES. 

not  have  to  be  removed,  but  horse-hair,  if  properly  placed  very  close  to 
the  margin  of  the  integument  and  of  the  mucous  membrane,  does  not 
have  to  be  taken  out,  as  in  the  course  of  a  few  days,  if  the  first  knot  be 
tied  tightly,  it  always  cuts  through  the  suture  hole  and  comes  away  with 
the  little  brown  serous  scab,  leaving  a  perfect  line  of  union.  Erections 
make  no  difference  in  the  healing  if  the  dorsal  slit  is  made.  This  leaves 
a  loose  suture  line.  As  many  as  twenty  or  twenty -five  sutures  may  be 
applied,  the  first  one  being  placed  at  the  raphe  and  the  second  one  in  the 
centre  of  the  dorsum,  and  then  as  many  more  on  either  side  between  these 
points  as  may  be  necessary  to  obtain  close  apposition  of  the  wound  sur- 
faces. To  prevent  the  horse-hair  ends  from  turning  in  and  their  points 


FIG.  39.— Circumcision  V.    Operation  completed.    Horse-hair  sutures. 

irritating  the  glans  (since  in  many  cases  a  little  redema  occurs  causing 

the  suture  line  to  roll  inward),  the  ends  of  the  hairs  should  be  left  about 

one  inch  long  (Fig.  39).     After  forty-eight  hours  they  should   all  be 

trimmed  down  close  to  the  serous  scab,  which  will  have  formed.     When 

the  scab  falls  spontaneously,  the  sutures  will  come  away  unnoticed  in  it, 

saving  a  dry  line  of  union.     In  children  this  is  a  valuable  feature  of  the 

aon,  because  the  little  patients  do  not  like  to  have  the  wound  dressed 

touched  in  any  way.     The  operation  being  completed  the  parts  are 

ad,  ai  d  the  line  of  incision  is  dusted  with  a  little  astringent  antiseptic 

ler,  such  as  nosophen  or  aristol.     No  bandage  or  dressing  of  any 

J  required.     It  is  hard  to  keep  in  place,  only  irritates,  and  is  abso- 

tely  unnecessary.     A  contrivance  in  the  shape  of  a  circular  roll,  made 


VENEREAL   WARTS. 


67 


of  an  ordinary  towel,  should  be  placed  about  the  penis,  that  the  member 
may  lie  sideways  against  it.  This  is  to  be  tied  to  the  body  with  four 
tapes,  one  around  each  thigh  and  two  to  a  waistband,  for  the  purpose  of 


a??'/' 


FIG.  40. 


keeping  the  bed-clothes  from  contact  with  the  penis  (Fig.  40).  It  is  a 
most  exceptional  occurrence  in  simple  cases  not  to  obtain  complete  union, 
but  if  from  any  cause  a  granulating  surface  is  left,  it  should  be  treated 
with  a  dusting-powder  or  stimulating  applications. 


CHAPTER  IV. 

INFLAMMATION  OF  URETHEAL  FOLLICLES  -  PERI  -  URE- 
THRAL  ABSCESS  -  CO  WPERITIS  -  PROSTATITIS  -  SEMI- 
NAL  VESICULITIS. 

THE  common  complications  of  urethritis  beyond  those  already  con- 
sidered-chordee,  balanitis,  etc—consist  of  inflammation  of  the  glands 
of  the  urethra,  folliculitis,  peri-urethritis,  cystitis,  prostatitis,  and  epi- 
didymitis,  which  occur  in  connection  with  the  chronic  as  well  as  the  acute 
form  of  the  disease. 

Inflammation  of  the  TJrethral  Follicles.-The  follicles  of  the  urethra 
always  participate  more  or  less  in  all  acute  inflammations  of  the  canal. 


FIG.  41.— Follicular  Abscess  Complicating  Urethritis  in  Different  Locations. 

In  chordee  the  follicles  at  the  affected  spot  are  certainly  involved,  and 
may  be  the  route  by  which  the  inflammation  reaches  the  deeper  tissues. 
These  mild  inflammations  get  well  spontaneously,  as  a  rule,  when  the 
surface  congestion  goes  down. 

The  cause  of  follicular  inflammation  of  the  urethra  is  found  in  some 
form  of  local  irritation  to  the  already  congested  canal  or  during  an  attack 
of  urethritis,  such  as  irritating  injections,  frequent  erections,  nocturnal 
emissions,  etc.  When  a  single  follicle  or  a  group  of  follicles  is  attacked 
by  an  extension  of  inflammation,  each  one  may  be  felt  under  the  skin, 
generally  on  the  floor  of  the  urethra,  like  a  small  shot  or  pea.  When 


INFLAMMATION   OF   URETHRAL   FOLLICLES. 


69 


the  follicular  mouth  becomes  closed  during  the  course  of  such  an  inflam- 
mation, an  abscess  is  formed  in  the  dilated  sac  of  the  follicle,  which  event- 
ually discharges  itself  externally  through  the  skin,  or  internally  through 
the  natural  duct  of  the  follicle  (Fig.  41).  When 
an  external  opening  occurs,  urethral  fistula 
may  be  the  ultimate  result.  A  favorite  site 
of  these  follicular  abscesses  is  behind  the 
meatus  in  the  fossa  navicularis,  on  one  or 
both  sides  of  the  frenum.  The  inflammation, 
if  unabated,  may  extend  from  these  follicles 
into  the  cellular  tissue,  peri-urethral  inflam- 
mation (Fig.  42).  When  a  cellular  inflamma- 
tion occurs,  the  outline  of  the  follicle  is  gen- 
erally lost,  a  phlegmon  is  formed  which  is  not 
likely  to  undergo  resolution,  but  discharges 
itself  either  externally  or  internally,  or  both. 
In  the  latter  instance,  as  in  the  case  of  a  fol- 
licular abscess,  a  urethral  fistula  may  result. 

Treatment. — At  the  onset  the  treatment 
of  follicular  and  peri-urethral  inflammation 
should  be  antiphlogistic — rest,  freedom  from 
all  local  irritation,  and  mild  antiseptics,  if  any 
local  measures  be  adopted.  Irritating  injec- 
tions should  be  positively  avoided.  If  irri- 
gations of  permanganate  of  potassium  are  being 
used,  they  may  be  continued  under  light  pres- 
sure in  mild  strength  (1 :  6000) .  The  external  application  of  ten  to  twenty 

per   cent  of   ichthyol   oint- 
ment is  sometimes  useful. 

When  suppuration  occurs 
and  the  abscess  points  ex- 
ternally, an  incision  through 
the  skin  should  be  made  to 
evacuate  the  pus,  except 
when  the  follicular  abscess 
presents  near  the  meatus 
and  can  be  reached  from 
the  interior  (Fig.  43).  In 
this  instance  an  internal  in- 
cision should  be  made  and 
the  abscess  treated  on  the 
inside,  thereby  often  pre- 
venting the  formation  of  a 

FlG.  43.— Follicular  Abscess  in  the  Fossa  Navicularis.  ^fi^ol 

Preparation  lor  incision  through  meatus. 


FIG.  42.— Peri-Urethral  Abscess 
Involving  Follicles  on  the  Floor 
of  the  Urethra. 


70 


VENEREAL,  DISEASES. 


A  most  satisfactory  mode  of  treating  these  abscesses  after  they  have 
discharged,  whether  externally  or  internally,  is  by  the  injection  into  the 
cavity  of  a  small  quantity  of  the  ethereal  solution  of  peroxide  of  hydrogen 
(pyrozone),  commencing  with  twenty-five-per-cent  (caustic)  solution  so 
as  to  destroy  the  unhealthy  tissue  and  continuing  with  the  same  strength, 
or  with  the  weaker  five-per-cent  (antiseptic)  solution  at  intervals  of  one 
or  two  days  between  each  application.  By  this  method  a  rapid  contrac- 
tion and  closure  of  the  sac  is  produced  and  the  danger  of  fistula  may  b 
avoided.  These  solutions  are  applied  by  means  of  a  pipette,  which  is 
drawn  to  a  very  fine  point  (Fig.  44). 

Other  methods  of  treating  these  abscesses  are  based  upon  general  sur- 
gical principles  of  antisepsis  and  drainage,  which  require  that  after  the 


FIG.  44.— Treatment  of  Follicular  Abscess  from  Interior. 

abscess  is  opened  it  should  be  washed  at  regular  intervals  with  antisep- 
tic solution,  and  made  to  heal  from  the  bottom  by  packing  with  gauze. 

Inflammation  of  Cowper's  Glands. — This  is  another  form  of  follicular 
inflammation  of  the  urethra  which  occurs  in  the  glands  of  the  bulbous 
portion  known  as  Cowper's  glands,  cowperitis  and  perl-cowperitis.  The 
causes  are  much  the  same  as  in  follicular  inflammation  in  other  portions 
of  the  urethra,  some  kind  of  direct  local  irritation  or  traumatism  during 
an  attack  of  urethritis,  generally  gonorrhceal. 

The  primary  symptom  of  this  complication  is  pain  in  the  perineal 
region,  which  when  occurring  during  the  acute  stage  of  urethritis  should 
always  suggest  the  possibility  of  inflammation  in  one  of  these  glands. 
Examination  reveals  a  painful  and  indurated  swelling  in  the  perineum, 
corresponding  to  the  locality  of  Cowper's  glands,  generally  on  one  side 
nly.  ^  It  is  important  to  recognize  this  condition  at  its  onset,  as  in  the 
majority  of  instances,  when  discovered  early  enough,  resolution  may  be 


INFLAMMATION  OP  COWPER'S   GLANDS. 


71 


brought  about  by  antiphlogistic  measures.  When  this  latter  course  is 
not  taken,  suppuration  occurs,  characterized  by  the  enlargement  of  the 
swelling  in  a  more  or  less  oval  shape,  somewhat  pointed  toward  the  anal 
region.  The  swelling  later  diffuses  itself  into  the  surrounding  tissues, 
pericoivperitis,  and  extends  forward  in  front  of  the  scrotum  (Fig.  45) .  The 
surface  of  the  skin  reddens,  the  tumor  softens, 
having  in  some  cases  reached  the  size  of  a 
hen's  egg. 

When  suppuration  occurs,  the  abscess 
may  open  both  into  the  urethra  and  through 
the  perineum,  and  is  liable  to  leave  urethro- 
perineal  fistula.  More  often,  however,  the 
tumor  resolves  without  suppuration,  especial- 
ly if  recognized  early  and  properly  treated. 

Certain  cases  that  have  suppurated  and 
discharged  in  one  or  both  directions,  notably 
if  not  well  treated  or  if  the  general  health 
be  undermined,  terminate  in  chronic  cow- 
peritis  with  internal  or  external  fistula,  or 
both,  a  very  obstinate  and  annoying  malady. 
If  there  be  complete  urethro-perineal  fistula 
it  may  permit  leakage  during  urination,  or 
the  size  of  the  fistula  may  be  too  small  to 
allow  the  passage  of  a  visible  quantity  of 
urine  and  be  only  demonstrable  by  injection. 

There  are  no  symptoms  peculiar  to  cow- 
peritis  beyond  those  of  pain,  swelling,  in- 
duration, and  suppuration  corresponding  to 
the  anatomical  situation  of  Cowper's  glands, 
occurring  during  the  course  of  acute  ure- 
thritis.  The  diagnosis  therefore  based  upon  these  symptoms  is  not  diffi- 
cult. When  recognized  early  it  should  not  be  confounded  with  perineal 
inflammation  or  urinary  infiltration.  Its  location  should  differentiate  it. 
When  there  is  a  general  peri-cowperitis  its  recognition  is  more  difficult, 
and  a  distinction  between  it  and  urinary  infiltration  from  the  urethra 
may  be  troublesome,  but  the  latter  is  usually  a  result  of  tight  stricture  or 
of  old  chronic  inflammation  of  long  standing. 

While  malignant  disease  and  tubercle  do  occur  in  this  region,  they 
have  been  very  seldom  observed.  In  distinguishing  either  one  of  these 
conditions  it  should  be  borne  in  mind  that  the  course  and  duration  of 
acute  cowperitis  are  rapid  and  short,  generally  not  lasting  over  five  or  six 
days,  while  both  tubercle  and  cancer  are  essentially  chronic  in  character. 
Generally  speaking,  a  chronic  cowperitis  which  persistently  resists  treat- 
ment should  lead  to  the  supposition  of  the  existence  of  underlying  tuber- 


FiG.  45.— Cowperitis.  Peri-ure- 
thral  abscess  beginning  in  Cowper's 
glands  and  extending  to  the  peno- 
scrotal  angle. 


72  VENEREAL  DISEASES. 

ole,   and  calls  for  careful  bacteriological  examination  of  the  pus  and 
fistulous  scrapings. 

Treatment,— As  already  stated,  it  is  most  important  to  recognize  cow- 
peritis  at  its  inception,  during  which  period  antiphlogistic  measures  are 
indicated,  poultices,  baths,  and  if  the  inflammation  be  sufficiently  intense, 
the  application  of  leeches  to  the  perineum.  Absolute  rest  should  be  en- 
joined and  all  direct  urethral  applications  discentinued.  As  soon  as  sup- 
puration becomes  evident  it  is  necessary  to  evacuate  the  pus,  and  for  this 
purpose  a  free  incision  should  be  made  over  the  most  prominent  point  of 
the  swelling.  The  abscess  should  be  washed  out  with  an  antiseptic  solu- 
tion and  the  cavity  packed  lightly  with  gauze,  for  the  purpose  of  en- 
couraging rapid  contraction  and  healing  from  the  bottom  toward  the  sur- 
face. As  soon  as  cicatrization  commences,  and  even  before  the  cavity 
has  contracted  completely,  the  same  method  suggested  for  the  treatment 
of  follicular  abscess  of  the  urethra  is  to  be  recommended  here — namely, 
the  injection  of  the  ethereal  solutions  of  peroxide  of  hydrogen  (pyrozone), 
at  first  every  day  and  later  every  second  or  third  day,  in  the  hope  of 
causing  a  complete  closure  of  the  fistulous  tract.  At  the  beginning  of 
this  treatment,  when  the  surface  to  be  treated  is  large,  it  is  well  to  begin 
with  the  five-per-cent  solution  of  this  preparation,  and  when  the  cavity  has 
contracted  down  to  a  fistulous  canal  the  twenty-five-per-cent  caustic  solu- 
tion may  be  resorted  to  with  good  effect.  In  many  instances  this  treatment 
may  result  in  the  complete  closure  of  the  fistula.  When  these  means  fail, 
the  alternative  is  the  complete  extirpation  of  the  fistulous  tract  and  of  the 
indurated  mass  of  glandular  tissue. 

ACUTE  AND  CHRONIC   PBOSTATITIS. 

Prostatitis. — Etiology :  Acute  prostatitis  is  quite  often  a  complication 
of  gonorrhoea,  but  it  also  attends  non-specific  urethritis,  notably  when 
stricture  is  present,  and  it  may  occur  in  connection  with  sexual  strain, 
masturbation,  pre-existent  prostatic  disease,  tubercle,  cancer,  or  from 
traumatism. 

The  rheumatic,  scrofulous,  and  tuberculous  diatheses  are  predisposing 
causes,  while  sexual  excitement,  alcoholic  excess,  over-exercise,  and 
traumatism— especially  instrumental— during  an  attack  of  urethritis, 
may  be  the  determining  factors  in  its  production. 

Follicular  Prostatitis.— Mild  prostatitis  is  a  common  complication  of 
acute  urethritis  after  it  has  invaded  the  posterior  urethra.  Confined  mostly 
to  the  surface  and  to  the  follicles  of  this  portion  of  the  urethra,  it  is  not, 
when  properly  treated,  of  long  duration.  The  prostatic  urethra  becomes 
congested  and  swollen.  Granulations  may  form  on  the  surface  of  the 

jous  membrane.  The  superficial  follicles  of  the  prostate  may  become 
engorged,  and  their  mouths  dilated  with  contained  pus,  which  may  ex- 
ude and  give  rise  to  a  purulent  discharge. 


ACUTE  AND   CHRONIC   PROSTATITIS.  73 

The  symptoms  consist  of  a  somewhat  urgent  and  frequent  desire  to 
urinate,  which  varies  more  or  less  according  to  the  intensity  of  the  in- 
flammation. The  desire  to  urinate  may  persist  after  the  bladder  has 
been  emptied,  and  there  is  likely  to  be  pain  at  the  end  of  the  urinary  act. 
The  coexistence  of  a  certain  amount  of  urethro-cystitis  or  inflammation 
of  the  neck  of  the  bladder  is  more  than  likely.  The  above  symptoms 
resemble  closely  those  of  the  latter  disorder.  Besides  the  presence  of  a 
certain  amount  of  urethral  discharge,  the  urine  is  purulent  and  the  pres- 
ence of  pus  from  the  posterior  urethra  may  be  demonstrated  by  washing 
out  the  forward  canal  before  the  urine  is  voided.  Sometimes  a  few  drops 
of  blood  trickle  away  after  the  urinary  act. 

Parenchymatous  Prostatitis. — The  foregoing  description  refers  to  a 
mild  type  of  prostatitis.  A  higher  grade  of  the  malady  involves  the 
parenchyma  of  the  organ,  and  may  or  may  not  result  in  prostatic  abscess 
and  periprostatitis. 

When  prostatitis  attacks  the  body  of  the  gland,  the  latter  becomes 
increased  several  times  its  normal  size ;  its  consistence  is  firm  and  resist- 
ant ;  the  tissues  are  engorged  with  blood  and  distended  with  an  exuda- 
tion which  is  at  first  serous  and  later  of  a  purulent  character.  Sometimes 
one  half  of  the  gland  is  more  enlarged  than  the  other,  and  sometimes 
lumps  and  nodes  are  felt  upon  the  surface  on  account  of  irregular  distri- 
bution of  the  inflammatory  process.  The  gland  throbs  when  palpated  by 
rectal  touch. 

Abscess  of  the  prostate  occurs  as  a  result  of  the  formation  of  multiple 
pus  foci,  which  are  distributed  throughout  the  glandular  structure  and 
later  unite  into  one  pus  sac  of  variable  size,  which  is  generally  located  in 
the  posterior  portion  of  the  lateral  lobes.  More  rarely  small  hemorrhagic 
infarctions  occur  in  the  gland,  varying  in  size  from  a  small  pearl  to  that 
of  a  pea,  which  become  the  point  of  departure  of  the  prostatic  abscess 
(Desnos). 

In  the  early  stage  these  small  pus  collections  are  separated  by  thick 
and  resisting  walls.  Sometimes  they  are  seated  beneath  the  urethral 
mucous  membrane  and  more  rarely  beneath  the  mucous  membrane  of  the 
rectum.  Later  the  dividing  walls  give  way  and  the  small  sacs  communi- 
cate with  each  other.  The  accumulated  pus  is  gelatinous  and  thick. 
Generally  the  ejaculatory  ducts  become  thickened  and  filled  with  pus  and 
the  seminal  vesicles  may  also  suppurate — acute  vesiculitis. 

When  the  abscess  perforates  in  the  direction  of  the  urethra  the  result- 
ing cavity  fills  up  more  or  less  slowly,  according  to  the  rapidity  of  the 
healing  process.  Sometimes  it  remains  for  a  long  period  and  becomes 
the  site  of  a  chronic  prostatitis  connecting  with  the  urethra.  At  other 
times  the  abscess  evacuates  by  way  of  the  rectum  or  departs  in  different 
directions  through  the  enveloping  fascia,  in  which  case  a  periprostatic 
abscess  is  formed  which  involves  inflammation  of  the  recto-vesical  space. 


74  VENEREAL  DISEASES. 

Periprostatic  abscess  may  arise  from  other  causes,  wounds  or  lacera- 
tion of  the  rectum,  from  inflammation  of  the  bladder  or  seminal  vesicles, 
but  most  commonly  it  is  propagated  from  the  prostate  gland.  The 
extension  of  inflammation  takes  place  through  the  venous  and  lymphatic 
vessels  or  is  diffused  through  the  cellular  tissue  (Guyon). 

A  phlegmon  located  in  this  region  varies  in  its  size  and  activity 
according  to  the  cause  and  nature  of  its  production.  When  it  is  diffused 
through  the  cellular  tissue  the  cavity  may  become  limited  and  remain  for 
a  long  time.  When  it  is  propagated  through  a  lymphangitis  or  phlebitis 
it  is  apt  to  be  more  extensive  and  of  more  serious  import.  The  abscess 
is  not  formed  by  the  combination  of  several  smaller  foci,  but  is  generally 
one  separate  cavity.  A  notable  feature  is  that  the  neighboring  organs 
are  not  of  necessity  greatly  influenced  by  the  proximity  of  this  inflamma- 
tion. It  is  possible  to  have  extensive  periprostatic  suppuration  accom- 
panied by  a  relatively  small  amount  of  functional  disturbance.  On  the 
other  hand,  the  neighboring  organs  may  be  affected  and  may  participate 
in  the  inflammatory  process.  Sometimes  a  large  cavity  communicating 
with  the  bladder  or  a  fistulous  tract  in  the  rectum  may  remain  after 
evacuation  of  the  abscess.  At  other  times  recto-urethral  fistula  is  the 
result. 

Symptoms  and  Course. — In  follicular  prostatitis  complicating  acute  or 
chronic  urethritis,  the  symptoms,  as  stated,  vary  in  intensity  with  the 
grade  of  the  inflammation  and  consist  of  more  or  less  urgent  desire  to 
urinate,  and  a  seuse  of  itching  or  discomfort  in  the  perineal  region.  The 
desire  to  urinate,  however,  is  not  uncontrollable,  and  the  intervals  between 
the  calls  may  be  nearly  normal  unless  there  coexists  inflammation'  of  the 
neck  of  the  bladder. 

In  severe  cases  pain  in  the  prostatic  region  persists  after  the  bladder 
has  been  emptied,  and  the  flow  of  urine  is  followed  by  the  passage  of 
several  drops  of  blood.  The  first  flow  of  urine  always  contains  a  certain 
amount  of  pus,  derived  from  the  prostatic  sinus  or  from  the  suppurating 
follicles. 

Acute  prostatitis,  involving  at  once  the  whole  gland,  is  sharp  in  its  on- 
set, sometimes  preceded  by  a  chill  and  accompanied  by  marked  pyrexia. 
Attention  is  immediately  attracted  to  the  prostate  by  the  pain  in  the 
penneal  region,  attended  by  a  dragging  or  bearing-down  sensation. 
These  symptoms  often  supervene  after  the  unwise  or  careless  use  of 
instruments  in  the  posterior  urethra.  When  the  symptoms  run  high,  the 
possibility  of  prostatic  abscess  should  be  borne  in  mind.  The  pain  upon 
irination  becomes  intense,  the  few  drops  of  urine  remaining  in  the  blad- 
der causing  frequent  and  violent  vesical  spasm.  Between  the  paroxysms 
the  calls  to  urinate  are  not  imperative,  as  is  the  case  in  cystitis. 

ain  in  the  rectum  is  also  complained  of;  defecation  intensities  it  and 
provokes  vesical  and  rectal  spasm.     If  the  prostate  be  examined  by  the 


ACUTE   AND   CHRONIC    PROSTATITIS.  75 

rectum,  it  is  found  to  be  hot,  swollen,  throbbing,  and  intensely  painful. 
The  enlargement  may  be  symmetrical  or  confined  to  one  lateral  half. 
Such  examination  may  excite  in  the  patient  an  irresistible  impulse  to 
evacuate  both  the  bowel  and  the  bladder. 

Suppuration  occurring  in  the  substance  of  the  prostate  gland  during 
an  attack  of  acute  prostatitis  is  marked  by  rigors  and  chills,  increase  in 
the  fever,  and  general  malaise.  The  local  symptoms  become  aggravated, 
the  sensitiveness  being  so  great  that  every  movement  of  the  body  intensi- 
fies the  pain.  Defecation  is  rendered  almost  unbearable.  All  of  these 
intense  symptoms  cease  almost  instantly  after  the  evacuation  of  the  pus 
when  the  malady  takes  this  favorable  turn,  which  is  generally  the  case. 
Sometimes,  however,  general  sepsis  comes  on,  the  chills  continue,  the 
temperature  mounts,  and  the  indications  point  toward  general  systemic 
infection.  This  unfavorable  course  is  of  grave  import  and  menaces  life. 

Prostatic  abscess  generally  breaks  toward  the  urethra.  Rupture 
usually  occurs  spontaneously  during  straining  at  stool  or  the  spasmodic 
efforts  attendant  upon  urination.  When  the  evacuation  of  pus  is  com- 
plete, recovery  is  progressive;  but  when  the  evacuation  is  incomplete,  all 
the  foci  not  being  freely  drained,  grave  complications  are  to  be  feared — 
septicaemia,  infiltration  of  urine.  Recovery  may  also  be  retarded  by  the 
too  rapid  closure  of  the  opening,  causing  the  pus  to  burrow  in  other 
directions  and  leading  to  the  formation  of  multiple  openings  (Desnos). 
Not  infrequently  the  pus  burrows  toward  the  rectum,  and  either  dis- 
charges directly  into  the  bowel  or  more  commonly  diffuses  itself  into  the 
cellular  tissue  between  the  prostate  and  the  rectum — periprostatic  abscess. 
When  this  complication  ensues,  rectal  examination  detects  the  general 
diffusion  of  the  inflammatory  thickening,  blotting  out  the  limits  of  the 
prostate  gland.  Laterally  the  tissues  surrounding  the  prostate  effec- 
tually limit  the  course  of  the  pus,  but  below  the"  resistance  is  less  and 
there  the  pus  diffuses  itself  and  may  open  into  the  urethra,  the  rectum, 
the  ischio-rectal  fossa,  or  the  perineum.  The  double  opening  into  urethra 
and  rectum  is  common,  yielding  urethro-rectal  fistula. 

Diagnosis. — Follicular  prostatitis  occurring  during  an  attack  of  gonor- 
rhoea is  recognized  by  an  increased  urgency  and  frequency  of  urination, 
the  occurrence  of  pus  in  both  flows  of  the  urine,  and  usually  by  a 
coincident  cessation  of  purulent  discharge  from  the  meatus.  These 
symptoms,  however,  also  occur  in  cystitis,  and  these  two  conditions  are 
likely  to  coexist — hence  the  term  urethro-cystitis  (page  89). 

When  inflammation  attacks  the  body  of  the  gland,  most  of  the  sub- 
jective phenomena  are  intensified,  and  marked  constitutional  symptoms 
appear,  chills,  rigors,  pyrexia,  etc.,  notably  when  suppuration  occurs. 
Unless  the  vesical  neck  be  also  implicated,  there  may  be  little  or  no  fre- 
quency of  the  urinary  call.  Rectal  examination  will  detect  a  hard,  pain- 
ful tumor  of  unequal  proportions,  and  sometimes  a  fluctuating  point. 


ipg  VENEREAL  DISEASES. 

Prostatitis  involving  the  body  of  the  gland  and  cystitis  are  often  con- 
founded. Desnos  has  modified  and  improved  the  table  of  differential 
diagnosis  prepared  by  Fournier. 

Cystitis.  Prostatitis. 

1.  Characteristic     vesical    tenesmus.  1.  Vesical  tenesmus  less.     Rectal  te- 
Frequent  desire  to  urinate  imperative.  nesmus  more  marked. 

2.  Urination  especially  painful  dur-  2.  Urination    distressing    or    painful 
ing  the  passage  of   the  last  drops    of  during  the  whole  act. 

urine,     accompanied    by    characteristic 
spasm. 

8.  With  the  last  portion  of  the  urine          3.  Urine  ordinarily  normal, 
expression  of  a  purulent  or  bloody  flow, 
often  even  of  pure  blood. 

4.  Slight  perineal  pain  radiating  in          4.  Perineal  pain  marked,  very  intense, 
the  region  of  the  anus,  much  less  violent      increased  by  movements,  defecation. 
than  in  prostatitis. 

5.  Prostate  normal.  5.  Prostatic  tumor,  very  sensitive  and 

hard. 

6.  No  complete  retention  of  urine.  6.  Difficulty    in    passing    the    urine, 

sometimes  retention. 

7.  Few  or  no  general  symptoms.  7.  General    symptoms    very    marked, 

fever,  etc. 

Cowperitis  is  distinguished  by  recognizing  the  seat  of  the  inflamma- 
tion to  be  the  anatomical  region  of  Cowper's  gland  in  front  of  the  deep 
urethra  and  by  excluding  prostatitis  by  rectal  examination.  A  seminal 
vesiculitis  may  be  present  with  the  same  symptomatology  as  that  of  pros- 
tatitis, but  is  easily  recognized  at  the  onset  by  rectal  examination. 

When  periprostatitis  occurs,  the  swelling  diffuses  itself  in  the  sur- 
rounding tissues,  including  the  seminal  vesicles,  and  the  recognition  of 
the  original  trouble  may  then  be  much  more  difficult. 

Treatment, — The  treatment  of  acute  follicular  prostatitis  is  that  of 
posterior  urethritis,  which  see. 

The  aim  of  treatment  in  acute  parenchymatous  prostatitis  should  be 
to  prevent  the  occurrence  of  suppuration,  and  calls  for  antiphlogistic 
measures.  Hot  sitz-baths  or  hot  applications  to  the  perineum  are  gener- 
ally a  source  of  comfort  to  the  patient,  in  which  case  they  should  be  used 
freely.  In  very  acute  cases  the  application  of  cups,  leeches,  or  a  blister 
to  the  perineum  is  desirable,  for  the  purpose  of  relieving  the  inflamed 
organ  by  lowering  its  tension.  Anodynes  may  be  given  to  allay  pain, 
which  is  sometimes  exceedingly  acute  and  often  remains  in  spite  of  the 
use  of  such  remedies,  pushed  almost  to  the  point  of  narcotism.  Mor- 
phine hypodermically  and  suppositories  of  opium,  belladonna,  and  cocaine 
may  be  employed.  Confinement  to  bed  is  essential.  No  other  medicinal 
treatment  has  any  particular  value.  The  diet  should  be  plain,  the  bowels 
be  assisted.  The  urine,  if  highly  charged  and  acid,  should  be  diluted  by 
alkaline  diuretics,  and  if  retention  occur,  the  catheter  must  be  used  very 


ACUTE   AND    CHRONIC   PROSTATITIS.  77 

regularly  and  with  the  utmost  gentleness.  It  is  generally  the  case  in 
acute  parenchymatous  prostatitis  that  relief  from  the  acute  pain  is  not 
had  until  the  tension  in  the  gland  is  relieved  by  the  subsidence  of  the 
inflammation ;  or,  when  suppuration  occurs,  until  the  evacuation  of  the 
pus.  When  it  becomes  evident  that  pus  has  formed,  it  must  be  let  out 
at  once.  As  already  stated,  the  abscess  may  point  toward  the  urethra, 
the  rectum,  or  the  perineum.  When  it  points  toward  the  urethra  it  often 
leads  to  urinary  retention,  and  the  pus  escapes  either  spontaneously  or 
during  the  use  of  the  catheter.  Superficial  fluctuation,  detected  by  rectal 
touch,  calls  for  puncture  through  the  wall  of  the  gut.  If  the  pus  be 
deeply  seated,  a  more  surgical  and  better  drainage  is  attained  by  the  pre- 
rectal  incision,  dissection  being  carefully  made  upward  until  pus  is  reached. 
The  advantage  of  this  method  is  that  urinary  fistula  is  quite  certainly 
averted.  Nature  even  is  sometimes  intelligent  enough  to  elect  this  route, 
in  which  instance  a  superficial  incision  is  all  that  is  required.  The  cavity 
is  then  washed  out  with  hot  normal  salt  solution,  and  if  the  hemorrhage 
be  great,  it  is  packed  with  absorbent  gauze.  The  gauze  may  be  removed 
in  twenty-four  or  forty-eight  hours,  and  replaced  or  not,  as  seems  best. 
The  after-treatment  consists  in  keeping  the  external  opening  pervious 
until  the  cavity  contracts  down,  which  should  be  encouraged,  if  neces- 
sary, by  stimulation.  This,  however,  is  generally  not  required,  as,  when 
proper  drainage  is  afforded,  the  cavity  rapidly  contracts. 

CHRONIC  PROSTATITIS. 

This  malady  is  usually  a  direct  propagation  by  continuity  of  chronic 
posterior  urethritis,  and  it  may  yield  symptoms  of  so  little  note  as  some- 
times to  be  entirely  overlooked  and  disregarded,  consisting  only  of  a  little 
sticky  discharge  which  usually  glues  together  the  meatus  in  the  morning. 
At  other  times  the  discharge  is  more  copious  and  annoying. 

Prostatorrhosa  is  a  disorder  which  resembles  chronic  prostatitis,  in 
that  it  is  a  mild  and  chronic  condition  accompanied  by  few  or  no  symp- 
toms othex  than  a  small  amount  of  urethral  discharge  appearing  at  vary- 
ing intervals.  The  discharge  in  prostatorrhcea  is  not  muco-purulent,  but 
simply  an  excess  of  the  normal  prostatic  secretion ;  and  the  malady  has 
not  necessarily  any  venereal  origin.  These  two  troubles  are  often  con- 
founded and  the  terms  used  interchangeably. 

Sturgis1  has  directed  attention  to  this  confusion  that  exists  in  the 
printed  descriptions  of  the  two  maladies,  and  has  clearly  accentuated  the 
points  of  difference.  Chronic  prostatitis  then  is  a  latent  inflammation, 
a  remnant  of  pre-existing  acute  trouble ;  whereas  prostatorrhcea,  a  more 
rare  disorder,  consists  in  a  leakage  of  the  prostatic  secretion  due  to  the 

'Journal  of  Cutaneous  and  Gen  i  to-Urinary  Diseases,  June,  1898. 


78  VENEREAL  DISEASES. 

relaxation  of  the  mouths  of  the  prostatic  ducts,  and  may  be  caused  by 
masturbation,  excessive  sexual  indulgence,  etc.  Both  of  these  maladies 
are  liable  to  be  attended  by  various  reflex  nervous  phenomena,  psychical 
disturbances,  and  sexual  debility  and  neurasthenia.  The  significance  of 
the  discharge  is  overestimated  by  the  patient,  who  often,  particularly  in 
prostatorrhoaa,  imagines  that  the  flow  is  a  seminal  loss,  and  he  therefore 
aggravates  all  his  symptoms  by  mental  introspection.  Instead  of  this 
mild  type  of  prostatitis  which  approaches  so  nearly  to  prostatorrhcea, 
there  is  another  type  in  which  the  suppuration  in  the  prostatic  sinus  is 
very  profuse,  the  dilated  sinus  containing  not  drops  of  pus  but  drachms, 
as  may  be  demonstrated  by  washing  out  the  pouch.  One  or  more  of  the 
follicles  of  the  prostate  may  be  distended  with  pus,  which  exudes  from 
their  dilated  mouths  into  the  prostatic  sinus.  There  may  exist  an  inter- 
stitial prostatic  pus  cavity,  the  remnant  of  an  old  prostatic  abscess,  which 
has  not  contracted  down.  Examination  per  rectum  in  chronic  paren- 
chymatous  prostatitis  will  detect  prostatic  enlargement,  generally  unsym- 
inetrical,  sometimes  nodular,  and  pressure  upon  the  gland  will  express  a 
quantity  of  its  fluid  contents,  which  will  consist  of  pus  cells  and  prostatic 
secretion,  differing  from  that  which  is  obtained  by  pressure  in  a  case  of 
prostatorrhoea,  which  consists  of  prostatic  secretion  pure  and  simple,  and 
is  devoid  of  the  products  of  inflammation. 

There  is  an  interstitial  form,  of  chronic  prostatitis  involving  cellular 
infiltration  of  the  gland  and  the  obliteration  of  its  glandular  elements  by 
the  formation  of  new  fibrotic  tissue.  Such  a  condition  may  eventually 
lead  to  atrophy,  contraction,  and  diminution  in  the  size  of  the  organ. 
There  is  no  distinct  line  of  demarcation  between  the  follicular,  the  par- 
enchymatous,  and  the  interstitial  forms  of  prostatitis,  any  one  of  which 
may  occur  alone.  They  are  liable  to  coexist,  and  the  classification  is 
more  or  less  arbitrary.  • 

Symptoms.  — Chronic  prostatitis  often  exists  without  any  symptoms  of 
sufficient  moment  to  attract  the  attention  of  the  patient,  and  this  may  be 
true  of  active  as  well  .as  of  light  cases.  A  chronic  follicular  prostatitis 
involving  the  ejaculatory  ducts  and  the  prostatic  sinus  may  be  attended 
by  pain  during  the  sexual  act  and  a  certain  amount  of  purulent  discharge. 
A  much  higher  grade  of  trouble,  involving  even  interstitial  changes  and 
parenchymatous  inflammation,  may  exist  without  a  corresponding  increase 
in  the  intensity  of  the  symptoms.  Heat  and  bearing  down  in  the  peri- 
neum or  rectum  are  sometimes  complained  of.  Neuralgic  pains  radiating 
down  the  legs  and  toward  the  fundus  of  the  bladder  sometimes  are  the 
chief  annoyance.  Reflex  nervous  symptoms  and  mental  depression  are 
often  present,  but  belong  equally  to  the  clinical  history  of  all  chronic 
isturbances  of  the  genital  apparatus,  and  therefore  are  not  pathogno- 
monic.  Functional  impotence  occurs  or  premature  ejaculation  due  to 
hyperaesthesia  of  the  ejaculatory  ducts.  Sterility  is  possible  from 


ACUTE   AND   CHRONIC   PROSTATITIS. 


79 


azoospermia,  caused  by  obstruction  of  the  seminal  ducts  or  by  inflam- 
matory cohesion. 

Prostatorrhqea,  or  excessive  flow  of  the  prostatic  secretion,  may  be 
present,  due  to  dilatation  of  the  excretory  ducts  of  the  prostate,  in  which 
case,  however,  inflammatory  products  are  found  mingled  with  the  pros- 
tatic discharge.  This  discharge,  as  in  prostatorrhcea  simplex,  may  be 
increased  by  movements  of  the  body  and  by  defecation.  True  sperma- 
torrhoea, as  shown  by  the  presence  of  spermatozoa  in  the  discharge,  the 


FIG.  46. 

result  of  inflammatory  catarrhal  dilatation  of  the  seminal  ducts,  often 
complicates  chronic  prostatitis.  The  prostate  is  always  sensitive  when 
examined  per  rectum,  a  feature  more  or  less  marked  in  different  individ- 
uals. The  nature  of  the  discharge  obtained  by  pressure  upon  the  prostate 
varies,  being  sometimes  a  free  gush  of  normal  prostatic  secretion  with  the 
admixture  of  a  small  amount  of  purulent  matter,  at  others  a  large  quantity 
of  pus  combined  with  only  a  few  of  the  elements  of  the  normal  prostatic 
fluid,  demonstrating  that  while  these  two  conditions  of  prostatorrhcea  and 
prostatitis  may  be  differentiated  theoretically,  yet  clinically  they  are  less 


80 


VENEREAL   DISEASES. 


easily  separated  and  are  liable  to  coexist.  Strictly  speaking,  prostator- 
rhoea  is  a  symptom,  not  a  disease — a  symptom  which  generally  enters  the 
clinical  history  of  prostatitis  more  or  less. 

Diagnosis. — A  strict  diagnosis  of  chronic  prostatitis  depends  upon  the 
character  of  the  prostatic  secretion  squeezed  out  by  digital  pressure  per 
rectum.  The  subjective  symptoms  are  not  to  be  relied  upon.  Micro- 
scopical examination  of  the  discharge  is  important  to  differentiate  prosta- 
titis, prostatorrhoea  simplex,  spermatorrhoea,  urethritis,  andurethrorrhcea. 


FIG.  47 


In  making  such  investigation  it  is  important  to  examine  first  the  discharge, 

my,  which  may  be  lying  in  the  anterior  urethra;  next,  that  which  is 

m  the  urine  after  the  anterior  urethra  has  been  washed  or  after  the 

iow  of  urine;  and  finally  that  which  is  found  in  the  last  urine 

er  tne  prostate  shall  have  been  manipulated  through  the  rectum.     The 

icalcharacter  of  the  urethral  discharge  is  known  to  vary  in  the  diifer- 

:ions  named.     A  purulent  discharge  signifies  an  inflammation  in 

>r  or  posterior  portion  of  the  canal.     Prostatorrhoea  simplex,  as 

ed,  yields  an  excess  of  prostatic  secretion,  which  escapes  fa 


rom 


ACUTE  AND   CHRONIC   PROSTAT1TIS. 


81 


the  urethra  spontaneously  and  during  muscular  effort.  Such  a  discharge 
is  neutral  or  mildly  acid  in  reaction.  It  has  the  seminal  odor.  It  is 
white  in  appearance  and  is  smooth  and  slippery.  A  microscopical  exami- 
nation reveals  the  accompanying  picture,  which  contains  amyloid,  hyaline, 
and  lecithin  bodies,  epithelium  and  Boettcher's  crystals  (Fig.  46),  the 
latter  being  seen  only  in  secretions  from  the  prostate  and  are  produced 
by  the  addition  of  a  one-per-cent  solution  of  phosphate  of  ammonia. 
This  secretion,  as  will  be  seen,  possesses  none  of  the  elements  of  inflam- 


FiG.48. 

mation.  Its  presence  here  would  indicate  the  coexistence  of  prosta- 
titis,  from  which,  theoretically  at  least,  prostatorrhoea  simplex  must  be 
clearly  distinguished. 

Urethrorrhoea  ex  libidine  consists  of  a  hypersecretion  from  the  glands 
of  the  urethra.  The  discharge  is  thin  and  watery,  sticky  and  tenacious, 
and  the  patient  may  notice  that  upon  placing  his  finger  over  the  meatus 
the  discharge  may  be  drawn  out  for  some  little  distance,  resembling  in 
this  particular  a  bit  of  gum  or  sap.  It  has  no  seminal  odor  and  it  consists 
microscopically  of  a  collection  of  flat  epithelial  cells  and  some  free  mucus, 
6 


82 


VENEREAL,  DISEASES. 


but  none  of  the  elements  which  are  found  in  the  secretion  of  a  prostator- 
rhoea  (Fig.  46).  This  discharge  is  also,  in  an  uncomplicated  case,  en- 
tirely free  from  the  elements  of  inflammation. 

Spermatorrhoea  produces  a  discharge  which  is  gelatinous  in  character, 
mildly  alkaline  in  reaction,  and  possesses  the  seminal  odor.  Microscopi- 
cally we  find  the  unmistakable  evidence  of  the  character  of  this  discharge 
in  the  presence  of  spermatozoa  (Fig.  48).  We  have  also  the  elements  of 
theprostatic  secretion,  and  in  inflammatory  conditions  we  find  the  elements 


FIG.  49. 


of  inflammation ;  but  the  presence  of  spermatozoa  in  a  secretion  from  the 
urethra  at  any  time  except  following  an  emission  is  the  one  sign  necessary 
to  determine  the  existence  of  spermatorrhoea,  which  condition  may  exist 
as  a  result  of  an  atonic  state  with  dilatation  of  the  seminal  ducts,  or  as  a 
symptom  of  prostatitis  or  vesiculitis.  The  discharge  of  prostatitis  may 
be  scanty  or  abundant.  It  oozes  spontaneously  from  the  urethra,  but  in 
order  to  establish  its  origin  it  is  better  first  to  wash  out  the  urethra  with 
warm  saline  or  boric-acid  solution  and  then  obtain  the  discharge  for  exam- 
ination from  the  first  flow  of  urine,  or  to  examine  that  which  is  expressed 


ACUTE  AND  CHRONIC   PROSTATITIS.  83 

from  the  gland  by  pressure  through  the  rectum.  The  gross  appearance  of 
this  discharge  is  more  or  less  purulent,  differing  from  that  of  prostatorrhoea 
and  that  of  urethrorrhoea  which  do  not  possess  this  characteristic.  It  has 
nothing  whatever  in  its  gross  appearance  to  distinguish  it  from  the  in- 
flammatory discharge  of  other  portions  of  the  canal,  and  it  is  therefore 
important  that  it  be  obtained  for  examination  after  the  anterior  urethra 
shall  have  been  cleansed.  It  is  a  difficult  matter  to  determine  by  micro- 
scopical examination  the  locality  from  which  the  epithelium  in  a  given 
specimen  is  derived.  The  exudation  from  a  chronic  prostatitis  will  pre- 
sent a  microscopical  picture,  as  shown  in  Fig.  49,  containing  granular 
phosphates,  leucocytes  and  epithelia,  and  in  addition  any  of  the  elements 
of  the  normal  prostatic  secretion  as  seen  in  prostatorrhoea  (Fig.  46)  may 
be  found. 

The  gross  appearance  of  the  urine  in  chronic  prostatitis  may  show  only 
the  presence  of  urethral  filaments  or  of  a  small  or  large  quantity  of 
free  pus.  In  locating  the  origin  of  urethral  filaments  or  of  the  free  pus, 
it  is  proper  to  take  the  precaution  of  first  cleansing  the  anterior  canal  and 
then  obtaining  the  urine  in  two  separate  flows.  The  first  flow  will  then 
wash  out  the  contents  of  the  prostatic  canal,  which  may  be  a  quantity  of 
free  pus  or  one  or  two  shreds  or  lumps,  and  the  latter  will  present  differ- 
ent appearances,  as  they  happen  to  be  more  or  less  granular  or  gelatinous. 
There  is  sometimes  a  solitary  shred  of  a  definite  tadpole  shape  as  though 
it  had  been  expelled  from  the  mouth  of  one  of  the  ejaculatory  ducts. 
Microscopically  they  are  composed  of  pus  cells  and  mucus,  and  also  may 
contain  any  of  the  other  elements  of  the  prostatic  or  seminal  secretion. 
The  examination  per  rectum  will  distinguish  any  alteration  in  the  size 
and  sensibility  of  the  prostate,  and  also  any  implication  of  the  seminal 
vesicles,  which,  if  distended  by  catarrhal  secretion,  may  be  felt  beyond 
the  prostate  on  either  side  of  the  base  of  the  bladder,  varying  in  size 
from  a  peanut  to  that  of  a  small  egg.  Cystitis  of  the  neck  of  the  bladder 
is  readily  identified  by  the  frequency  and  pain  of  urination,  notably  at 
and  after  the  expulsion  of  the  last  portion  of  urine,  and  often  by  the  ex- 
istence in  the  last  flow  of  a  greater  amount  of  pus  than  in  the  beginning. 
Cystitis  often  coexists  with  chronic  prostatitis. 

Treatment, — In  the  adoption  of  local  treatment  for  chronic  prostatitis, 
by  way  of  the  urethra,  certain  measures  have  been  recommended  which,  * 
in  our  opinion,  are  a  source  of  irritation  rather  than  a  means  of  relief. 
Such  are  the  unnecessary  passage  of  bougies  and  other  instruments  intended 
to  overdilate  the  canal,  and  the  use  of  medicated  bougies.  Some  cases 
of  chronic  prostatitis  require  about  the  same  treatment  and  management 
as  that  recommended  for  chronic  urethritis  (see  p.  43),  mild  irrigations  of 
permanganate  of  potassium,  about  1  :  4,000  to  6,000,  or  of  the  nitrate  of 
silver  or  corrosive  sublimate,  the  former  1  :  4,000  to  6,000  (and  when 
well  tolerated  even  stronger),  the  latter  1  :  12,000  to  16,000.  The 


84 


VENEREAL  DISEASES. 


method  of  irrigating  the  prostatic  urethra  has  been  already  described 
(page  28).  Instillations  are  also  often  found  useful  in  chronic  prosta- 
titis.  The  nitrate  of  silver  heads  the  list.  It  should  be  tested  gently, 
for  it  may  disagree.  It  is  used  in  a  solution  of  from  gr.  ss.  to  gr.  x.  to 
the  ounce,  and  sometimes  stronger,  and  probably  more  often  than  the 
other  preparations  because  it  is  quite  generally  effective,  often  brilliantly 
so.  A  few  drops  only  of  the  strong  solutions  are  needed,  the  quantity 
being  reduced  as  the  strength  of  the  solution  is  increased.  Thallin  and 


FIG.  50.— Tuttle's  Rectal  Tube. 

the  other  drugs  already  referred  to  (see  p.  47)  will  be  found  to  suit 
some  of  these  cases.  The  use  of  the  endoscope  in  the  posterior  urethra 
has  already  been  discouraged.  The  authors  of  this  treatise  can  do  better 
with  other  means.  It  is,  however,  advocated  by  some,  who  claim  better 
results  by  this  means  than  by  other  methods.  The  Griiufeld  endoscope 
is  advocated  for  the  purpose  of  making  direct  application  of  the  caustic 
agent,  nitrate  of  silver  or  chloride  of  zinc,  to  the  veru  montanum.  It  is 
not  clear  why  such  active  cauterization  of  the  veru  montanum  should  be 
better  than  gentler  astringent  applications  to  the  entire  prostatic  sinus, 
more  particularly  if  the  parenchyma  of  the  prostate  be  involved  as  well 
as  the  surface  of  the  mucous  membrane. 

To  reach  deep-seated  chronic  inflammatory  alterations  of  the  prostate, 


FIG.  51.— Chetwood  Tube  for  Rectal  Irrigation. 

such  measures  as  will  act  directly  upon  the  circulation  of  the  organ  may 
be  instituted.  One  of  these  is  massage  of  the  prostate,  accomplished  by 
the  finger  introduced  into  the  rectum.  Gentle  lateral  pressure  may  thus 
be  made  upon  the  prostatic  tissues,  while  at  the  same  time  the  secretion 
m  the  swollen  and  turgid  follicles  is  forced  out.  This,  both  to  the 


ACUTE   AND    CHRONIC   PROSTATITIS. 


85 


patient  and  the  surgeon  disagreeable  manipulation  is  sometimes  quite 
useful  in  very  chronic  cases.  Many  trained  nurses  and  massage  opera- 
tors understand  and  practise  it.  But  better  than  this  last  procedure  we 
consider  the  application  of  moist  heat  to  the  region  of  the  prostate  by 
rectal  irrigation.  It  is  a  fact  that  the  rectum  will  tolerate  a  very  high 
degree  of  temperature  when  employed  in  this  manner,  and  sometimes  by 
this  means  strikingly  beneficial  results  are  obtained  in  old  chronic  cases 
of  prostatitis  which  have  long  resisted  the  continued  efforts  directed  tow- 


ard  the  urethral  surface  of  the  gland.  The  figure  on  this  page  illustrates 
the  method  of  employing  the  hot-water  rectal  douche  by  means  of  a  tube 
especially  devised  for  this  purpose — a  modification  of  Tuttle's  or  Kemp's 
rectal  tube  (Fig.  51).  The  hot  water  from  a  fountain  syringe  passes 
into  one  arm  of  the  tube  and  enters  the  rectum  through  two  very  small 
apertures  on  its  circumference  near  the  distal  end.  A  large  opening  at 
the  extremity  connects  with  an  interior  tube  as  large  as  the  calibre  of  the 
outer  one  will  allow.  Through  this  the  immediate  return  of  the  hot 
water  from  the  rectum  takes  place,  and  thus  a  continuous  circulation  of 


86  VENEREAL  DISEASES. 

moist  heat  around  the  prostate  is  kept  up  so  long  as  the  operation  is  con- 
tinued, which  is  generally  from  ten  to  fifteen  minutes.  The  end  of  the 
tube  needs  a  little  manipulation  to  insure  continuous  outflow  of  the 
injected  fluid.  Instead  of  the  sitting  posture  which  is  assumed  in  the  ac- 
companying figure,  the  knee-chest  position  may  be  substituted  and  often 
with  better  results.  This  operation  should  be  conducted  every  night  for  an 
extended  period,  according  to  the  effect  produced.  Improvement  is  often 
noted  almost  immediately,  and  sometimes  it  is  surprising  to  discover  that 
in  the  absence  of  any  other  local  treatment  the  character  of  the  urine, 
which  had  been  thick  and  turbid  with  pus,  clears  up  promptly.  Most 
cases,  however,  are  less  brilliant,  and  it  is  sometimes  necessary  to  urge 
the  continued  use  of  this  rectal  tube  for  a  long  period  before  permanent 
results  are  obtained ;  but  when  improvement  has  taken  place  under  its 
use,  permanent  relief  may  be  hoped  for  if  the  douche  be  used  persist- 
ently. The  general  condition  of  the  patient  should  receive  attention,  and 
any  disturbances  of  nutrition  properly  treated.  Iron,  arsenic,  and  hypo- 
phosphites  have  their  indications  as  tonics,  and  cod-liver  oil  seems  to 
possess  a  special  value,  as  in  most  other  debilitated  conditions.  Pros- 
tatitis  may  be  tuberculous  in  character,  or  occur  in  individuals  who  have 
the  tuberculous  diathesis.  Indeed,  posterior  urethritis  is  not  infrequently 
the  exciting  cause  of  local  tuberculous  deposit.  Such  cases  naturally  do 
not  get  well  under  instillations,  irrigations,  or  the  rectal  douche.  Thallin 
sometimes  comforts  them,  and  the  hot  rectal  douche  does  the  same,  but 
radical  treatment  means  a  transportation  to  a  favorable  climate,  plus  the 
usual  internal  constitutional  remedies  directed  against  tubercle  wherever 
situated. 

INFLAMMATION  OF  THE  SEMINAL  VESICLES. 

Inflammation  of  these  organs,  or  spermatocystitis,  occurs  as  a  gonor- 
rhoeal  complication  following  severe  or  prolonged  suppuration  in  the  pos- 
terior portion  of  the  urethra.  It  frequently  coexists  with  inflammation 
of  the  prostate  and  often  with  acute  epididymitis,  but  in  such  cases  it  is 
a  side  issue  and  may  be  disregarded  until  the  epididymitis  shall  have 
disappeared.  Any  inflammatory  condition  existing  in  the  prostatic  sinus 
may  extend  by  continuity  into  the  vesicular  reservoirs,  but  gonorrhosal 
posterior  urethritis  is  more  liable  to  take  this  course  than  other  inflam- 
mations. It  is  claimed  by  some  that  this  propagation  of  inflammation 
from  the  prostate  is  by  way  of  the  blood-vessels  or  lymph  channels,  but 
the  claim  has  not  been  substantiated.  That  seminal  vesiculitis  may  exist 
as  a  separate  and  distinct  affection  there  is  no  possible  doubt,  but  it  is 
most  often  a  complication  of  gonorrhoea  which  has  invaded  the  posterior 
urethra. 

The  symptoms  of  acute  seminal  vesiculitis  resemble  those  of  acute 
posterior  urethritis  and  prostatitis;  sometimes  there  is  more  fever. 


INFLAMMATION   OF   THE   SEMINAL  VESICLES.  87 

They  are  a  sense  of  pressure,  pain,  and  rectal  tenesmus,  painful  erec- 
tions, and  sometimes  spermatozoa  in  the  urethral  discharge  and  purulent 
or  bloody  seminal  emissions.  This  latter  is  by  no  means  a  constant 
symptom.  Examination  per  rectum  will  detect  an  enlarged  and  tender, 
sometimes  fluctuating  mass  in  the  region  of  the  vesicles,  extending  from 
the  limit  of  the  prostate  upward  along  the  base  of  the  bladder  on  one  or 
both  sides.  \Yhen  abscess  forms,  as  is  sometimes  the  case,  it  may  dis- 
charge itself  forward  into  the  urethra  or  backward  into  the  rectum.  Such 
abscesses  have  been  known  to  point  into  the  abdominal  cavity,  causing 
fatal  peritonitis.  The  symptoms  not  being  entirely  distinctive  of  this 
disorder,  the  diagnosis  must  depend  upon  rectal  examination.  When 
vesiculitis  coexists  with  prostatitis,  the  swelling  and  infiltration  will  be 
found  to  destroy  the  line  of  separation  between  these  organs ;  but  when 
it  is  limited  to  one  or  both  vesicles,  a  careful  exploration  may  distinguish 
the  outline  of  the  prostate. 

Chronic  Seminal  Vesiculitis. — This  is  usually  a  natural  sequence  of 
the  acute  trouble,  or  may  come  on  insidiously  as  a  complication  of  the 
chronic  gonorrhceal  urethritis  which  has  invaded  the  posterior  urethra 
and  thence  extended  itself  to  the  prostate  and  vesicles.  It  is  often  due 
to  excessive  sexual  indulgence,  even  without  an  antecedent  gonorrhoea, 
or  to  the  abuse  of  venery  and  alcohol,  or  to  the  employment  of  harsh 
local  treatment  in  the  posterior  urethra  during  a  congested  or  inflamma- 
tory state.  It  is  probable  that  tuberculous  and  rheumatic  subjects  are 
more  prone  to  chronic  vesiculitis,  as  they  are  generally  more  likely  to  be 
the  victims  of  prolonged  and  intractable  attacks  of  posterior  urethritis. 

The  symptoms  of  chronic  vesiculitis  resemble  those  of  chronic  pros- 
tatitis, and  vary  greatly  in  severity.  Sometimes  there  is  no  symptom 
other  than  a  chronic  urethral  discharge,  which  has  resisted  all  the  various 
local  and  general  therapeutic  attacks.  In  addition,  there  may  be  noted 
frequent  nocturnal  pollutions,  bloody  or  purulent  in  character.  Altera- 
tions in  the  sexual  capacity  and  appetite  may  also  be  a  feature.  Neuras- 
thenic symptoms,  as  in  prostatitis,  are  commonly  present,  and  indefinite 
and  intermittent  pains  radiating  through  the  perineum,  down  the  thigh, 
and  into  the  hypogastric  and  lumbar  region  may  also  be  complained  of. 

Treatment. — The  treatment  of  seminal  vesiculitis  resembles  that 
adopted  for  acute  and  chronic  prostatitis.  During  acute  inflammation  rest 
and  freedom  from  all  sexual  excitement  are  imperative,  and  antiphlogis- 
tic measures  suitable  in  the  endeavor  to  avert  suppuration.  A  bland 
diet,  alkaline  diluents,  and  mild  laxatives,  together  with  hot  sitz-baths  or 
hot  applications  to  the  perineum,  are  all  in  order.  If  an  abscess  forms  in 
spite  of  these  measures,  its  contents  should  be  evacuated  by  a  rectal  in- 
cision as  soon  as  fluctuation  can  be  distinctly  made  out.  Massage  and  rec- 
tal douches  are  not  only  improper  in  the  acute  stage,  but  are  liable  to 
cause  irritation  and  do  harm.  When  the  abscess  has  discharged  itself 


38  VENEREAL  DISEASES. 

spontaneous!}'  or  by  incision  and  the  acute  symptoms  have  subsided,  treat- 
ment becomes  the  same  as  that  employed  in  the  chronic  condition. 

In  chronic  inflammation  of  the  seminal  vesicles  infiltration  and  vas- 
cular engorgement  of  these  pouches  exist  with  sometimes  narrowing  or 
occlusion  of  the  ejaculatory  ducts,  but  usually  catarrhal  dilatation.  The 
aim  of  treatment  is  to  facilitate  drainage  of  the  distended  catarrhal 
pouches  and  by  improving  the  circulation  to  overcome  the  catarrh.  For 
this  purpose  a  systematic  massage  of  the  vesicles  themselves  and  of  the 
adjacent  prostatic  region  has  been  strongly  advocated,  notably  by  Dr. 
Eugene  Fuller;  a  process  termed  "  stripping  the  seminal  vesicles  "  being 
relied  upon  to  effect  a  cure.  That  many  cases  are  benefited  by  this, 
what  may  be  called  drainage  method,  there  is  no  doubt ;  but  if  equally 
good  results  can  be  obtained  by  other  means,  the  irritation,  which  is 
sometimes  caused  by  pressure  upon  the  vesicles,  may  be  avoided,  and 
the  surgeon  will  necessarily  give  his  preference  to  another  equally  effec- 
tive procedure,  especially  as  the  regular  employment  of  the  alternative 
stripping  measure  is  not  agreeable,  and  may  be  as  well  carried  out  by  a 
trained  nurse.  For  this  purpose  we  have  used  in  many  cases  the  rectal 
irrigating-tube  already  referred  to  when  considering  the  treatment  of 
prostatitis  (page  85,  Fig.  52).  By  this  application  of  moist  heat  a 
beneficial  result  may  be  looked  for  in  this  region,  whether  the  inflamma- 
tion involve  the  prostate  alone  or  coexist  with  a  catarrhal  disteution  of 
the  seminal  vesicles.  This  hot-douche  irrigation  brings  about  the  same 
results  as  the  application  of  massage.  It  assists  the  overdistended  vesi- 
cle in  voiding  its  contents,  and  by  its  resolvent  action  upon  the  circula- 
tion encourages  resolution  of  long-standing  inflammation.  An  additional 
advantage  is  that  it  can  be  employed  by  the  patient  himself,  and  no 
matter  where  he  may  be,  it  is  generally  possible  for  him  to  obtain  the 
benefit  of  continuous  treatment  when  circumstances  might  not  permit 
him  to  make  frequent  calls  upon  his  physician.  In  long-standing  and 
chronic  cases,  like  massage  it  should  be  persisted  in  patiently  over  a  long 
period.  Some  cases  yield  to  it  which  have  not  been  favorably  influenced 
'by  massage.  Some  are  entirely  cured  by  it,  others  greatly  improved. 
Those  that  fail  to  improve  are  quite  likely  to  be  tuberculous  or  to  have 
prostatic  hypertrophy  or  contractured  vesical  neck,  conditions  equally 
unsuitable  for  massage.  The  last-named  condition— contracture  of  the 
neck  of  the  bladder— is  not  an  infrequent  result  of  prolonged  suppurative 
inflammation  in  the  posterior  urethra.  If  its  symptoms  are  urgent,  they 
call  for  perineal  cystotomy  for  the  purpose  of  incising  laterally  the 
fibrotic  ring,  a  means  which  alone  insures  relief  of  symptoms. 


CHAPTER   V. 

ACUTE  AND  CHKONIC   CYSTITIS.— EPIDIDYMITIS. 

INFLAMMATION*  of  the  neck  of  the  bladder  may  complicate  urethritis 
under  a  variety  of  circumstances.  It  very  rarely  occurs  spontaneously 
during  gonorrhoea.  Generally  some  immediate  exciting  cause  produces 
it.  Among  the  most  common  of  these  are  the  use  of  strong  injections, 
especially  if  thrown  too  deeply  into  the  canal  j  strong  and  continued 
sexual  excitement,  or  attempts  at  intercourse  during  a  gonorrhoea ;  excess 
in  physical  exertion  of  any  sort ;  abuse  of  liquor ;  excessive  use  of  cubebs, 
turpentine,  or  cantharides  j  the  use  of  instruments  in  the  urethra  during 
an  acute  attack,  or  at  any  stage  if  there  be  any  lack  of  perfect  gentleness 
in  manipulation  during  such  instrumentation. 

All  of  these,  and  certain  other  analogous  causes,  are  sufficient  to  excite 
gonorrhoeal  cystitis  in  a  patient  having  a  urethral  discharge,  although  the 
attack  itself  may  have  become  very  mild,  and  much  the  more  so  when 
the  symptoms  are  intense.  The  same  exciting  causes  are  also  sometimes 
productive  of  cystitis  when  the  urethritis  is  due  to  the  presence  of  stric- 
ture, and  not  very  infrequently  an  attack  of  mild  cystitis  comes  on  in  a 
patient  with  a  diseased  urethra,  the  exact  immediate  cause  of  which  can- 
not be  determined. 

Gonorrhoeal  cystitis  is  often  not  encountered  until  the  urethral  dis- 
charge has  been  active  for  several  weeks,  but  may  come  on  earlier. 

The  lesions  of  acute  gonorrhoeal  cystitis  are  generally  confined  to  the 
neck  of  the  bladder,  and  with  them  are  likely  to  coexist  lesions  of  the 
posterior  urethra.  The  term  urethrocystitis  has  been  applied  to  this 
condition,  signifying  inflammation  commencing  in  the  posterior  urethra 
and  extending  into  the  bladder,  where  it  is  limited  to  the  region  of  the 
trigone  and  internal  sphincter. 

Acute  cystitis  proper,  involving  the  entire  surface  of  the  vesical 
mucous  membrane,  is  a  rather  rare  complication  of  gonorrhoea,  but  does 
occur. 

In  urethrocystitis  the  mucous  membrane  in  the  vicinity  of  the  neck 
of  the  bladder  becomes  swollen,  red,  and  velvety,  in  continuation  of  a 
similar  condition  in  the  prostatic  urethra.  When  this  process  has  existed 
for  some  time  and  become  subacute  or  chronic,  the  neck  of  the  bladder  is 
covered  with  granulations;  while  if  the  entire  organ  is  involved,  the 


90 


VENEREAL  DISEASES. 


general  mucous  membrane  assumes  a  slate  color  and  a  reticulated  appear- 
ance, and  may  be  the  seat  of  ulcerations  or  small  abscesses.  If  this 
morbid  change  extends  still  farther,  a  "  parenchymatous  cystitis  "  is  the 
result,  the  deep  portions  of  the  mucous  membrane  are  implicated,  and  the 
muscular  coat  becomes  infiltrated. 

Finally  the  pelvis  of  the  kidney  on  one  or  both  sides  may  become 
invaded  from  propagation  of  the  inflammation  upward  through  the 
ureters.  The  gonococcus  is  found  in  the  pus  in  some  cases.  In  many 


FIG.  53.— Add  Cystitis.    Pus  corpuscles,  red  blood  cells,  and  bladder  epithelium. 


its  presence  cannot  be  demonstrated,  while  other   micro-organisms  are 
found  in  large  numbers. 

The  urine  in  gonorrhoeal  cystitis  varies  according  to  the  character  and 

ntensity  of  the  inflammation.     In  the  acute  stage  it  is  generally  acid, 

loaded  with  pus,  and  contains  epithelium  from  the  bladder  and  urethra, 

sometimes  blood  (Fig.  53).     When  decomposition  takes  place  within  the 

ier,  the   characteristic  crystals    of   ammonio -magnesium   or  .triple 

osphates,  amorphous  phosphates,    and   sometimes   urate  of  ammonia 

crystals  with  numerous  bacteria  are  seen  on  microscopical  examination 

*ig.  54).     Such  urine  is  alkaline  in  reaction  and  has  a  characteristic  foul 

ammoniacal  odor. 

Symptoms.— The  symptoms  of  gonorrhoeal  cystitis  vary  with  the  in- 


ACUTE   AND   CHRONIC   CYSTITIS. 


91 


tensity  of  the  inflammation.  They  are  frequent  desire  to  urinate,  ac- 
companied by  a  varying  amount  of  pain  and  urgency,  and  the  passage 
of  turbid,  purulent  urine. 

In  all  forms  of  cystitis  there  exists  a  certain  amount  of  urinary  urgency, 
which  while  mild  and  controllable  in  light  cases,  becomes  intense  and  im- 
perative in  the  acute  condition,  accompanied  by  sharp  pain  and  haematuria. 
The  blood  may  appear  as  a  coloration  of  the  last  drops  of  urine,  or  be 
of  sufficient  quantity  to  redden  the  entire  flow.  In  acute  urethro-cystitis 


FIG.  64.— Alkaline  Cystitis.     Pus  corpuscles,  bladder  epithelium,  crystals  of  triple  phosphates, 

and  bacteria. 

the  symptoms  are  mainly  those  of  acute  posterior  urethritis,  varying  in 
intensity  from  a  slightly  increased  desire  to  urinate,  with  bearing-down 
pain  toward  and  after  the  end  of  the  urinary  act,  to  a  much  greater 
urgency  in  the  calls,  which  become  as  frequent  as  every  quarter  to  half 
hour,  attended  perhaps  by  haematuria  due  to  the  high  grade  of  conges- 
tion. Each  spasmodic  effort  to  empty  the  bladder  rubs  together  the 
inflamed  surfaces  of  the  mucous  membrane  and  intensifies  the  condition. 
When  the  urine  is  passed  into  two  glasses  both  flows  are  turbid,  the 
second  being  as  cloudy  as  the  first,  and  sometimes  more  so.  If  the  urine 
is  passed  into  three  separate  glasses  the  third  flow  will  also  be  cloudy 
from  the  presence  of  pus,  sometimes  more  and  sometimes  less  so  than 


92  VENEREAL  DISEASES. 

that  in  the  first  glass ;  but  it  will  always  be  turbid,  which  is  not  the  case 
when  the  posterior  urethra  alone  is  involved.  Involuntary  urination  or 
false  incontinence  occurs  in  acute  cases  when  the  calls  to  urinate  are 
imperative,  the  patient  being  unable  to  restrain  the  bladder  contraction. 
Complete  retention  sometimes  occurs,  but  infrequently  and  as  a  result  of 
urethral  spasm,  whereas  incomplete  retention  due  to  swelling  of  the  tis- 
sues around  the  neck  of  the  bladder  is  less  uncommon. 

In  chronic  urethro-cystitis  the  symptoms  are  the  same  but  milder, 
and  as  time  goes  on  they  gradually  diminish  unless  the  vesical  neck  be- 
comes contractured,  in  which  case  they  persist  almost  indefinitely. 
Chronic  cases  are  always  subject  to  acute  relapse.  As  a  result  of  pro- 
longed chronic  inflammation  and  infiltration,  acting  as  an  obstruction  to 
the  evacuation  of  its  contents,  the  bladder  atonies  and  the  presence  of  a 
certain  amount  of  residual  urine  may  become  constant.  This  urine  may 
be  of  acid  reaction,  containing  all  the  elements  of  inflammation ;  or  if 
decomposition  has  set  in,  it  may  show  all  the  characteristic  elements  of 
ammoniacal  urine  (Fig.  54). 

As  urethro-cystitis  comes  on,  the  patient  at  first  passes  water  a  little 
more  often  than  usual  by  day  (sleeping  perhaps  through  the  whole  night), 
and  the  urethral  discharge  lessens,  which  is  taken  by  the  patient  to  be  a 
favorable  sign.  Soon,  however,  it  is  found  that  the  calls  to  urinate 
become  more  urgent.  Then  follow  pain  on  urination,  and  a  sharp, 
grinding,  bearing-down  pain  following  each  act  of  urination,  due  to  the 
fact  that  the  empty  bladder  continues  to  contract  and  squeezes  its  own 
tender  neck. 

From  this  time  on  there  is  a  constant  sense  of  weight,  a  dull  pain 
over  the  pubic  symphysis,  more  or  less  heat  and  discomfort  in  the  peri- 
neum, a  constant  sensation  of  fulness  of  the  bladder,  calling  for  repeated 
and  unavailing  straining  to  pass  water,  the  best  efforts  culminating  in  a 
spurt  of  only  a  few  drops  of  turbid  urine  full  of  pus  and  often  tinged 
with  blood.  When  this  state  has  been  reached  the  patient  may  become 
feverish,  with  dry  tongue,  parched  lips,  and  constipated  bowels. 

Gonorrhoeal  cystitis  generally  gets  perfectly  well  in  a  period  varying 
from  a  few  days  in  mild  cases  up  to  a  couple  of  weeks,  or  even  several 
months,  in  bad  cases.  Sometimes  permanent  irritability  is  left  behind, 
and  persists  as  a  chronic  cystitis,  with  more  or  less  fibrotic  thickening— 
contracture— of  the  vesical  sphincter  and  a  relative  amount  of  occlusion 
of  the  urethral  orifice  of  the  bladder. 

Treatment.— In  mild  cases  rest  upon  the  back  may  be  all  that  is  re- 
quired in  the  way  of  treatment.  The  application  of  heat,  as  in  a  hot- 
water  bottle,  affords  considerable  comfort  when  placed  over  the  bladder 
or  against  the  perineum. 

The  alkaline  diluent,  copaiba  or  sandal-wood  oil,  if  being  administered 
for  urethritis,  should  be  continued,  and  bland  drinks,  like  flaxseed  tea, 


ACUTE  AND   CHRONIC  CYSTITIS.  93 

elm-bark  decoction,  infusions  of  triticum  repens,  buchu,  afford  the  patient 
some  comfort,  but  do  not  do  much  good,  excepting  in  so  far  as  they  are 
mildly  diuretic. 

Diluent  mineral  waters  drunk  freely  are  unquestionably  of  value  in 
these  cases,  and  an  exclusive  milk  diet  has  a  peculiar  merit.  The  latter 
must  be  accompanied  by  enough  of  some  mild  vegetable  laxative  to  over- 
come its  constipating  tendency.  If  it  purges,  as  is  sometimes  the  case, 
skimmed  milk  may  be  substituted  for  whole  milk.  A  gallon  a  day  is  full 
diet  for  a  healthy  man.  If  so  much  can  be  managed  by  the  stomach, 
nothing  else  whatever  need  be  given  either  to  eat  or  to  drink. 

All  those  articles  of  food  and  drink  which  were  condemned  in  the 
dietetic  section  on  the  treatment  of  gonorrhoea  must  be  equally  avoided 
here. 

Hot  hip-baths  are  of  service.  The  heat  of  the  bath  should  range  in 
the  region  of  110°  F.,  the  pelvis  should  be  covered  by  the  water-line, 
and  the  bath  be  not  longer  than  three  or  four  minutes  in  duration.  Such 
baths  may  be  repeatedly  taken  every  few  hours  during  the  day  when  they 
afford  relief. 

As  for  medicines,  anodynes  hold  the  first  rank.  The  frequency  of 
urination  must  be  stopped.  The  following  combination  will  give  relief  in 
mild  cases : 

]$  01.  santal.  or  gaultherise, §  ss. 

Liq.  potassse, 3  ij.-vi. 

Tr.  hyoscyami, 3  vi. 

Syr.  acacise, q.s.  ad  §  iij. 

M.     S.  Teaspoonful  in  water  every  four  hours. 

Hyoscyamus  may  be  used  alone,  as  tincture,  in  half-drachm  doses  several 
times  a  day,  with  the  happiest  effect  in  the  cases  in  which  it  agrees. 

When  mild  measures  of  this  sort  fail  to  control  the  frequency  of 
urination,  a  positive  anodyne  must  be  employed.  Half-grain  or  whole- 
grain  suppositories  of  the  watery  extract  of  opium,  with  one-third  to  one- 
half  of  a  grain  of  the  extract  of  belladonna,  may  be  used  and  repeated 
often  enough  to  keep  the  intervals  of  urination  two  hours  long.  The 
belladonna  sometimes  disagrees.  A  tablet  triturate  of  codeine  (one- 
quarter  grain  every  three  or  four  hours)  may  be  used  for  the  same  pur- 
pose, to  keep  the  intervals  of  urination  two  hours  long  by  daylight,  or  an 
analogous  liquid  preparation : 

%  Elix.  opii  (McMunn), 3vi.-xij. 

Liq.  cascara  aromat., §  ss.-iss. 

Aq.  cinnamomi,  .        .        .        .        •        •       Q-S.  ad  ^  iij- 
M.     S.  Teaspoonful  three  or  four  times  a  day. 

By  persistence  in  these  means,  the  pain,  the  tenesmus,  and  the  fre- 
quency of  urination  will  gradually  subside,  and  the  discharge  begin  to 


94  VENEREAL  DISEASES. 

reappear  at  the  meatus.  For  this  return,  some  mixture  of  copaiba  should 
be  used  internally,  since  the  effect  of  this  drug  upon  the  bladder  is  often 
also  quite  beneficial.  The  following  capsule  is  a  good  one : 

S  Copaiba, ^  vii- 

Oleoresin.  matico, m,  iij. 

S.  Three  to  six  capsules  daily. 

At  this  stage  the  question  of  resuming  local  measures  against  the 
urethral  discharge  may  be  properly  considered. 

Local  Treatment. — During  the  most  acute  stage  of  gonorrhoeal  cystitis 
it  is  better  to  depend  upon  antiphlogistic  measures  and  the  internal  treat- 
ment, which  has  already  been  detailed.  Local  measures  are  generally  to 
be  interdicted  during  this  period,  as  they  are  liable  to  increase  the  irrita- 
tion rather  than  to  allay  it.  When  the  acute  stage  has  subsided,  however, 
and  in  subacute  and  chronic  cases  generally,  local  measures  are  decidedly 
indicated.  Some  cases  which  seem  to  be  irritated  by  local  applications 
are  benefited  by  irrigations  with  plain  hot  normal  salt  solution  or  boracic 
acid  three  per  cent.  Other  cases  are  decidedly  helped  by  irrigations  of 
permanganate  of  potassium  in  the  same  manner  as  employed  in  acute 
anterior  and  posterior  urethritis  (p.  29).  The  value  of  this  latter 
remedy  in  a  given  case  is  generally  quickly  determined.  If  the  benefit 
be  not  prompt,  the  irrigations  should  be  discontinued.  Solutions  of 
nitrate  of  silver  sometimes  prove  more  efficacious  than  any  other  remedial 
agent  in  the  treatment  of  gonorrhoeal  cystitis.  The  strength  of  such 
solutions  varies  from  1 : 16, 000  to  1  -.2,000,  according  to  the  tolerance  of 
the  bladder.  They  should  be  used  in  the  same  manner  as  the  perman- 
ganate of  potassium — that  is,  they  should  be  injected  into  the  bladder 
through  the  posterior  urethra  and  thus  their  beneficial  influence  exerted 
upon  this  latter  region.  If  after  the  cessation  of  the  acute  stage  of  cys- 
titis the  urethritis  has  recurred  and  is  accompanied  by  a  more  or  less 
copious  discharge  of  pus,  it  is  well  also  to  irrigate  the  anterior  urethra 
before  introducing  the  catheter  for  posterior  irrigation,  but  this  is  neces- 
sary only  when  anterior  urethritis  is  present.  If  permanganate  of  potas- 
sium is  being  employed  for  bladder  irrigation,  the  anterior  urethra  can  be 
irrigated  in  the  regular  way ;  but  if  the  nitrate  of  silver  is  being  employed 
in  the  bladder,  this  agent  should  not  be  used  for  anterior  irrigation,  as 
its  decidedly  astringent  effect  upon  the  urethra  will  interfere  with  the 
introduction  of  the  catheter  and  cause  considerable  annoyance.  If  irri- 
gation of  the  anterior  urethra  be  deemed  necessary,  the  permanganate  of 
potassium  should  be  used  for  this  purpose  or  the  urethra  may  be  syringed 
out  with  plain  boric  or  saline  solution.  Wheu  after  a  certain  period  the 
symptoms  of  cystitis  have  subsided,  and  the  examination  of  the  urine  in 
it  glasses  shows  that  the  trouble  has  concentrated  itself  in  the  posterior 
urethra,  the  bladder  irrigations  may  be  discontinued  and  the  treatment 


ACUTE  AND   CHRONIC   CYSTITIS.  95 

by  instillation   adopted   as  described  under  the  treatment  of  chronic 
urethritis  (p.  45). 

In  cases  of  chronic  cystitis  the  antecedent  cause  should  be  determined, 
as  the  persistence  of  such  cause  may  largely  influence  the  continuance  of 
the  bladder  inflammation.  In  this  we  refer  to  the  existence  of  stricture, 
chronic  prostatitis,  and  chronic  seminal  vesiculitis.  When  found  these 
conditions  should  be  properly  treated  as  has  been  detailed  under  their 
respective  headings.  The  treatment  of  chronic  cystitis  proper  requires 
local  applications  to  the  bladder  and  the  use  of  a  mild  non -stimulating 
diet.  Medication  should  vary  according  to  existing  conditions  in  a  given 
case,  as  revealed  by  urinary  examination  and  personal  idiosyncrasy.  A 
careful  examination  of  the  urine  should  be  made  in  all  cases.  As  already 
stated,  such  examination  will  show  purulent  urine  containing  various 
micro-organisms,  sometimes  acid  in  reaction  and  sometimes  alkaline  with 
ammoniacal  decomposition.  Alkalies  and  diluent  mineral  waters  are 
indicated  when  the  urine  is  strongly  acid  and  of  high  specific  gravity. 
Alkalies,  however,  should  be  used  with  discrimination  and  not  to  excess, 
as  hyperalkalinity  of  the  urine  is  to  be  guarded  against.  When  the 
urine  is  alkaline,  urotropin,  salol,  methyiene  blue  are  often  of  decided 
benefit  as  urinary  antiferments,  and  will  assist  in  restoring  the  urine  in 
the  bladder  to  its  normal  state.  From  gr.  xxx.  to  Ix.  of  salol  should  be 
given  daily  in  divided  doses.  One  of  the  formulae  put  up  in  capsule 
form  containing  salol  in  combination  is  also  sometimes  useful. 

FORMULA.  1. 

$  Salol.,     .        .        .        .       >       .        ,.',*•.        .  gr.  liiss. 

Oleoresin.  cubeb., ^l  v. 

Copaib.  Para,        .       :.        .        ...       •        •        .  m  x. 

Pepsin., .        .  gr.  i. 

Capsule  No.  1. 

FORMULA  2. 

$  Salol.,    .        .        .  .  .        .        .  .  .  .  gr.  iv. 

Oleoresin.  cubeb.,  .        .        .  •  •  .  m,  v. 

01.  santal.,     .        .  .  .        ...  .  .  mv. 

Pepsin.,          .        .  .  .        .        .  .  .  •  gr- i- 

Ol.  oliv.,        .        .  .  ....  .  *  .  mv. 

Capsule  No.  1. 

From  six  to  eight  of  one  or  the  other  of  the  above  capsules  may  be 
given  in  each  twenty -four  hours.  Occasionally  salol  disagrees  with  the 
stomach,  especially  in  large  doses.  It  may  in  such  cases  color  the  urine 
a  smoky  green  when  it  should  be  stopped. 

Bacteruria  is  a  constant  symptom  of  chronic  cystitis,  and  sometimes 
very  difficult  to  overcome.  As  already  stated,  salol  is  sometimes  very 
useful  in  re-establishing  the  normal  aseptic  condition  of  the  urine. 
When  this  drug  fails,  one  of  the  other  internal  antiseptics  may  be  resorted 


gg  VENEREAL   DISEASES. 

to.  Methylene  blue  in  capsule  form,  gr.  ij.  three  times  a  day,  is  given 
for  this  indication,  and  often  with  good  effect.  It  rapidly  colors  the 
urine  bluish-green,  and  is  objectionable  on  this  account  as  it  is  liable  to 
stain  the  patient's  linen  and  sometimes  deranges  the  stomach  and  bowels. 
Urotropin,  the  ammonia  salt  of  formaldehyde,  has  been  recommended 
as  a  uric-acid  solvent  and  as  an  internal  antiseptic.  In  some  cas^s  its 
effect  is  markedly  beneficial  in  conditions  of  pyuria  or  bacteruria,  and 
in  others  it  seems  to  be  a  source  of  irritation  to  the  stomach  and  mucous 
membrane  of  the  urinary  tract.  It  may  be  given  in  five-  to  ten-grain 
doses  from  three  to  six  times  daily,  in  tablets  or  in  powder  form. 
Cystogen  is  an  analogous  preparation  which  may  be  given  in  the  same 
quantity. 

The  local  treatment  of  chronic  cystitis  calls  for  bladder  irrigations  of  a 
rather  more  stimulating  character  than  in  the  acute  form.  The  perman- 
ganate of  potassium  is  sometimes  useful.  Nitrate  of  silver,  when  well 
tolerated,  should  be  employed  in  increasing  strength  from  1:4,000  to 
1 : 2,000,  sometimes  even  1 : 1,000.  Bichloride  of  mercury  in  solutions  of 
from  1:16,000  to  1:10, 000  and  protargol,  1:1,000  to  1:250,  are  also 
used.  There  is  no  given  rule  upon  which  to  base  a  selection  of  one  or 
the  other  of  these  remedial  agents  in  the  local  treatment  of  chronic 
cystitis,  as  their  beneficial  effect  is  not  constant  for  all  cases,  some  being 
aided  by  one  and  some  by  another  preparation.  When  after  a  long  use  of 
local  treatment  chronic  cystitis  seems  to  resist  all  the  measures-  adopted, 
perineal  cystotomy  should  be  considered  for  the  purpose  of  affording  pro- 
longed drainage  to  the  inflamed  organ.  If  this  expedient  be  decided 
upon,  the  bladder  should  be  opened  by  a  central  perineal  incision,  as  de- 
scribed in  the  treatment  of  stricture;  and  if  it  be  found  that  the  bladder 
is  covered  with  velvety  granulations,  the  curette  may  be  resorted  to  with 
perfect  safety  and  often  with  excellent  effect.  If  contracture  and  hyper- 
trophy of  the  vesical  sphincter  be  discovered,  as  is  often  the  case,  a 
rigid  vesical  orifice  resisting  the  exploring  finger,  this  obstruction,  which 
explains  the  persistence  of  the  chronic  cystitis,  should  be  cut  down 
freely  by  a  lateral  incision  with  a  long  blunt-pointed  bistoury  introduced 
into  the  bladder  under  the  guidance  of  a  grooved  director,  the  depth  of 
the  cut  being  estimated  by  a  finger  passed  into  the  rectum,  toward  and 
upon  which  the  incision  is  made. 

GONORKHCEAL   EPIDIDTMITIS — SWELLED    TESTICLE. 

Epididymitis,  as  a  complication  of  gonorrhoea  or  urethritis,  is  more 
frequent  in  hospital  than  in  private  practice,  where  Bergh  finds  it  in 
about  seven  per  cent  of  the  cases,  while  Taylor  places  it  at  not  over  two 
to  three  per  cent.  Like  gonorrho3al  cystitis,  it  may  come  on  in  regular 
sequence  as  a  result  of  the  gradual  spreading  downward  of  the  urethral 


EPIDIDYMITIS.  97 

inflammation,  from  the  posterior  urethra  to  the  mouth  of  the  ejaculatory 
duct,  and  thence  through  the  vas  deferens  to  tho  testicle.  Its  most  com- 
mon date  of  appearance,  in  the  course  of  a  gonorrhoea,  is  during  the  first 
three  or  four  weeks. 

The  date  of  appearance  of  epididymitis,  however,  is  by  no  means 
fixed.  It  may  come  on  during  the  first  few  days  as  a  result  of  irritating 
injections,  and  it  may  be  encountered  at  any  period  later,  or  even  at  any 
time  afterward  during  life.  Stricture  of  the  urethra,  or  rather  posterior 
urethritis  so  constantly  existing  behind  it,  is  a  fertile  source  of  epididy- 
mitis. Both  testicles  are  attacked  with  equal  frequency,  but  not  simul- 
taneously. Epididymitis  is  generally  unilateral,  and  when  both  testicles 
are  swelled  one  follows  the  other  by  an  interval  more  or  less  long. 

Generally,  epididymitis  is  due  to  some  direct  exciting  cause  over  and 
above  the  general  inflammation  of  the  urethra.  Among  such  immediate 
causes  may  be  enumerated  most  of  those  irritants,  general  and  local, 
which  have  been  referred  to  already  as  being  capable  of  lighting  up 
cystitis  in  a  patient  with  gonorrhoea,  such  as  injections  too  irritating  in 
quality  or  thrown  too  deeply  into  the  canal;  the  passage  of  a  sound  or 
other  instrument,  for  exploratory  or  other  purposes,  down  a  urethra 
which  is  the  seat  of  surface  inflammation;  sexual  irritation  of  any  sort; 
drinking;  violent  exercise,  which  may  act  by  directly  damaging  the 
testicle  mechanically,  and  thus,  as  it  were,  calling  down  the  inflammation 
from  the  urethra. 

Ordinary  swelled  testicle  is  usually  a  direct  sequence  of  posterior 
urethral  inflammation.  This  inflammation  extends  through  the  vas 
deferens,  producing  inflammation  of  the  duct  (deferentitis)  and  lodges  in 
the  epididymis  alone  (epididymitis)  or  occasionally  extends  farther  into 
the  testicle  (epididymo-orchitis).  A  testicle  once  attacked  by  epididy- 
mitis is  rather  prone  to  relapse  later  on  in  life,  more  vulnerable,  as  it 
were,  than  its  sound  companion. 

Epididymitis  is  accompanied  by  considerable  swelling  of  the  organ, 
firm,  resistant,  due  to  inflammatory  exudation  and  interstitial  changes, 
consisting  chiefly  in  infiltration  of  lymphatic  cells.  This  condition  may 
involve  the  testicle  and  the  vas  deferens.  There  is  generally  effusion  into 
the  tunica  vaginalis  and  sometimes  active  inflammation  of  its  walls.  Ab- 
scess may  result,  but  is  infrequent.  Examination  of  the  serous  fluid  in 
the  tunica  vaginalis  has  revealed  the  presence  of  pathogenic  micro-organ- 
isms and  sometimes  the  gonococcus,  but  ihis  latter  does  not  play  the  most 
important  etiological  role  in  this  complication. 

Symptoms. — When  acute  epididymitis  is  about  to  attack  a  healthy 
testicle,  sometimes  signs  of  warning  may  be  appreciated  twenty-four 
hours  before  the  testicle  begins  to  swell.  The  first  sign  is  generally  an 
uneasiness  referred  to  the  depths  of  the  groin,  upon  the  side  about  to 
become  affected,  with  a  sense  of  weight  and  uneasiness  in  the  testicle  of 
7 


93  VENEREAL  DISEASES. 

that  side,  which  is  usually  already  somewhat  over-sensitive  to  handling. 
With  these  symptoms  there  may  be  some  general  malaise,  a  little  consti- 
pation, slight  headache,  a  trifling  fever. 

These  symptoms  are  quite  apt  to  come  on  in  the  afternoon  after  a  day 
of  ordinary  exercise. 

The  patient  naturally  keeps  still  with  the  pain  in  his  groin  or  testicle, 
and  the  rest  of  an  evening,  or  a  night,  or  both,  often  makes  him  so  com- 
fortable that,  upon  awaking  the  next  morning,  he  may  not  be  conscious 
that  he  has  any  unusual  pain  until  he  is  upon  his  feet — possibly  not  then. 
Indeed,  after  quite  a  marked  prodromal  stage,  a  night's  rest  sometimes 
dissipates  the  pains,  and  the  patient  becomes  and  remains  well. 

This  fortunate  result  is  rare.  Generally,  as  the  day  goes  on,  the 
pain  in  the  groin  becomes  more  intense,  the  testicle  rapidly  or  gradually 
grows  heavy,  hot,  and  painful.  The  enlargement  usually  commences  in 
the  upper  and  back  portions — the  globus  major — and  runs  down  the  body 
of  the  epididymis;  sometimes  the  lower  part  or  globus  minor  is  first 
involved. 

The  portion  affected  is  acutely  sensitive  to  pressure;  the  remainder 
is  not  so.  At  this  stage  the  different  divisions  of  the  epididymis  and  its 
separation  from  the  body  of  the  testicle  can  be  readily  marked  out. 

Inflammation  and  swelling  of  the  cord  may  occur  simultaneously  with 
that  of  the  epididymis,  or  later  on.  There  may  be  a  sharp  chill,  followed 
by  intense  fever,  nausea,  headache,  and  vomiting.  Constipation  is  apt 
to  be  present,  and  sometimes  there  is  a  tendency  to  frequency  in  urination, 
with  more  or  less  pain  in  the  act. 

The  flow  of  pus  from  the  urethra  becomes  diminished,  or  stops  entirely, 
to  the  delight  of  the  patient,  who  indulges  in  the  vain  hope  that  that 
part,  at  least,  of  his  misfortunes  at  last  is  over.  The  relief  from  ure- 
thral  trouble  is  only  transitory,  and  the  discharge  will  return  as  the 
inflammation  in  the  testicle  subsides. 

The  fever  increases  at  first  as  the  testicle  swells,  and  to  the  intense 
and  increasing  pain  in  the  groin  is  added  often  an  intolerable  splitting 
pain  in  the  back,  low  down.  Meantime  as  the  testicle  increases  in  all 
its  dimensions,  fluid  generally  collects  in  the  tunica  vaginalis,  keeping 
the  testicle  oval  in  shape.  The  scrotum  gets  red  and  hot,  and  is  some- 
times the  seat  of  a  very  considerable  cedematous  effusion. 

The  intensity  of  the  symptoms,  and  the  height  to  which  the  inflam- 
mation reaches,  vary  greatly  in  different  cases.     There  may  be  nothing 
more  than  a  little  tension  of  the  epididymis,  the  size  of  a  hickory  nut, 
most  marked  posteriorly,  lasting  only  a  few  days,  and  totally  relieved  by 
e  recumbent  posture,  if  the  testicle  be  at  the  same  time  elevated  and 
apported.     On  the  other  hand,  the  suffering  may  be  intense,  the  scrotum 
tot,  red,  and  shining,  the  pain  in  the  groin  and  back  excruciating,  the 
;umca  vaginalis  tense  and  full  of  fluid,  the  substance  of  the  whole  testicle 


EPIDIDYMITIS.  99 

seemingly  in  a  state  of  most  active  inflammation,  and  this  condition  is 
not  relieved  either  by  position  or  by  support  to  the  testicle.  In  such 
severe  cases  the  body  of  the  testicle  probably  participates  in  the  inflam- 
matory condition  (epididymo-orchitis)  as  well  as  the  tunica  vaginalis 
(vaginalitis)  and  the  vas  deferens  (funiculitis,  deferentitis).  The  swollen 
cord  may  be  felt  running  up  the  groin,  where  it  is  excessively  sensitive 
to  pressure.  In  epididymo-orchitis  there  is  an  increase  in  the  testicular 
swelling  and  a  greater  amount  of  serous  effusion  into  the  tunica  vaginalis ; 
the  anatomical  boundaries  cannot  be  distinguished  and  the  general  swell- 
ing becomes  very  great. 

First  attacks  of  epididymitis,  like  first  attacks  of  gonorrhoea,  are 
usually  much  more  formidable  in  their  symptoms  than  subsequent  visita- 
tions of  the  same  malady.  In  the'  subacute  form  of  epididymitis,  espe- 
cially in  a  testicle  which  has  been  the  seat  of  former  attacks,  the  whole 
malady  may  consist  in  a  hard  lump,  which  appears  at  the  globus  minor 
or  major,  attended  by  more  or  less  pain,  dragging,  and  constitutional 
symptoms.  This  lumpiness  usually  remains  long  present,  perhaps  for 
months  or  even  years,  becoming  finally  almost  or  quite  insensitive,  and 
not  responding  at  all  to  medication. 

In  the  acute  cases  it  generally  takes  from  two  days  to  a  week  for  the 
increase  in  size  of  the  testicle  to  reach  its  height,  after  which  the  swell- 
ing goes  down — at  first  slowly,  then  quite  promptly,  so  that  in  ten  days 
or  two  weeks,  under  treatment,  it  may  be  counted  upon  with  reasonable 
certainty  that  the  most  desperate  case  will  be  practically  well — that  is, 
free  from  pain  to  such  an  extent  that  it  may  be  supported  in  a  suspensory 
bandage,  or  at  least  strapped,  and  thus  the  patient  be  allowed  to  get  about 
in  comfort. 

Complications  and  Sequelae. — Epididymitis  may  attack  the  undescended 
testis.  The  gland  may  have  reached  the  inguinal  canal  when  its  recogni- 
tion is  not  difficult,  or  it  may  not  have  left  the  abdominal  cavity.  In  the 
latter  instance  general  peritonitis  is  a  possible  result. 

Abscess  complicating  epididymitis  is  uncommon  except  in  the  case  of 
old  men  with  prostatic  disease.  Its  occurrence  in  the  young  suggests  the 
existence  of  a  tuberculous  diathesis.  Gangrene  of  the  scrotum  is  phenom- 
enal. It  occurs  only  in  connection  with  a  morbid  constitutional  disorder, 
such  as  Bright's  disease  or  diabetes. 

Atrophy  of  the  testis  is  reported  in  a  few  cases  as  a  sequel  to  epi- 
didymitis, and  hypertrophy  is  somewhat  more  common,  especially  after 
recurrent  attacks.  If  there  be  atrophy  there  must  have  been  also  orchitis. 
Chronic  infiltration  of  the  epididymis  often  remains  behind  for  an  in- 
definite period,  and  in  some  individuals  this  hard  focus  relapses  into  a 
subacute  epididymitis  from  time  to  time.  It  is  probable  in  such  in- 
stances that  there  is  coexistent  chronic  inflammation  of  the  seminal 
vesicle  or  prostate,  or  both.  Chronic  Jiydrocele  is  also  favored  by  this 


JQ0  .  VENEREAL  DISEASES. 

inflammatory  induration,  and  is  not  infrequently  found  as  a  sequel  of 

swelled  testicle. 

Neuralgia,  amounting  to  paroxysmal  pain  or  constant  acute  sensitive- 
ness of  the  organ  itself  or  in  the  region  of  the  cord,  reflex  neuralgic  pains, 
sometimes  of  a  very  intense  character,  radiating  along  the  course  of  the 
lumbar  and  sacral  nerves,  are  common  sequels  of  epididymitis,  especially 
in  neurotic  subjects  and  when  chronic  thickening  remains. 

Azoospermia  occurs  as  a  sequel  to  bilateral  epididymitis,  producing 
sterility.  An  acute  attack  of  the  affection,  if  it  passes  over  within  a 
reasonable  time,  leaves  no  injury  to  the  epididymis  behind  it;  but  the 
subacute  attacks — those  characterized  by  localized  large  nodular  de- 
velopments in  the  tail  or  head  of  the  epididymis — are  apt  to  fail  to 
get  entirely  well,  and  as  a  consequence  the  convoluted  tube  constitut- 
ing the  epididymis  becomes  obliterated  at  the  point  occupied  by  the 
nodule,  and  the  passage  of  spermatozoa  through  it  becomes  mechanically 
impossible. 

Inflammation  in  the  epididymis  results  in  plastic  exudation.  The 
calibre  of  the  tube  becomes  filled  up  as  the  morbid  process  advances,  and 
the  connective  tissue  in  which  the  tubes  lie  becomes  the  seat  of  a  similar 
plastic  inflammation.  This  process  thickens  the  whole  epididymis  by 
new  connective-tissue  deposits,  and  fuses  together  into  a  solid  mass  the 
convolutions  of  the  canal  of  the  epididymis.  The  canal  shows  irregular 
dilatations  and  contractions  at  the  seat  of  the  lesion ;  caseous  degeneration 
may  subsequently  attack  the  whole  mass,  and  in  cachectic  or  tuberculous 
subjects  tuberculous  infiltration  may  supervene.  Gosselin  pointed  out 
that  localized  epididymitis  of  the  tail  of  the  testicle  was  more  apt  to  pro- 
duce sterility  than  when  the  head  of  the  epididymis  alone  was  involved 
in  the  disease,  the  reason  being  that  many  tubes  unite  to  form  the  globus 
major,  while  the  globus  minor  is  composed  of  the  convolutions  of  a  single 
tube. 

The  sterility  encountered  after  gonorrhceal  epididymitis  is  present 
only  when  both  testicles  have  been  diseased,  and  not  necessarily  then. 
This  sterility  has  no  connection  with  impotence.  The  patient's  virile 
powers  are  as  strong  as  ever,  his  sexual  act  is  perfect.  Yet  the  fluid  ejac- 
ulated is  not  healthy  sperm.  It  has  the  spermatic  odor  but  is  watery  in 
quality,  and  apparently  composed  entirely  of  fluids  from  the  seminal 
vesicles  and  from  the  prostatic  follicles,  and  when  careful  microscopic 
examination  has  failed  to  detect  any  spermatozoa,  the  patient  is  necessarily 
sterile,  although  he  is  not  at  all  impotent. 

Time  may  effect  a  cure  in  some  cases  in  which  absorption  of  the  in- 
flammatory thickening  takes  place,  but  usually  neither  time  nor  treat- 
ment is  of  the  least  avail. 

Many  patients,  knowing  that  prolonged  chronic  epididymitis  on  both 
sides  is  liable  to  entail  the  loss  of  the  power  of  procreation,  may  come  to 


EPIDIDYMITIS.  101 

demand  an  opinion  as  to  their  capacity  to  beget  a  child.  The  only 
grounds  upon  which  such  an  opinion  can  be  honestly  rendered  are  (pre- 
sumptive) the  existence  of  a  lumpy  indurated  condition  of  the  epididymis 
on  both  sides,  and  (positive)  the  entire  and  continued  absence  of  sperma- 
tozoa from  the  spermatic  fluid. 

Treatment. — Here,  as  in  all  the  possible  complications  of  urethritis, 
"an  ounce  of  prevention  is  worth  a  pound  of  cure."  A  snug  suspensory 
bandage  should  be  worn,  and  all  such  exercise  as  might  jolt  or  bruise  the 
testicle  must  be  strictly  enjoined.  The  patient  should  be  kept  particularly 
quiet  during  the  acute  periods  of  the  urethral  discharge,  and  cautioned 
against  the  least  approach  to  sexual  excitement.  All  those  articles  of 
food  or  drink  which  are  known  to  increase  the  intensity  of  the  urethral 
inflammation  also  tend  to  produce  epididymitis,  and  must  be  avoided; 
and  much  care  is  necessary  in  the  selection  of  proper  injections,  as  well 
as  in  the  manner  of  administering  the  latter. 

The  treatment  of  epididymitis  varies  somewhat  with  the  grade  of 
intensity  of  the  inflammation.  During  the  premonitory  twenty-four 
hours,  when  the  principal  complaint  is  of  a  slight  weight  or  dragging  at 
the  cord  in  the  groin,  with  perhaps  some  discomfort  in  the  testicle  and  a 
pain  in  the  back,  a  strong  solution  of  guaiacol,  from  twenty-five  to  fifty 
per  cent,  and  sometimes  pure  guaiacol  applied  to  the  scrotum  over  the 
site  of  the  swelling  may  produce  prompt  and  marked  relief.  This  remedy 
may  be  combined  with  glycerin  or  vaseline  in  the  above  proportion.  The 
pain  attending  an  application  of  pure  guaiacol  is  very  intense  in  most 
cases.  Unless  under  the  guaiacol  the  symptoms  shall  have  abruptly 
subsided,  it  is  proper  to  put  the  patient  to  bed  upon  his  back,  to  admin- 
ister a  brisk  laxative,  and  to  sling  the  testicle  well  up  so  that  the  cord 
may  be  entirely  relieved  from  its  weight,  while  the  return  circulation 
from  the  testicle  is  favored  by  gravity. 

This  slinging-up  of  the  testicle  is  a  most  important  matter  during  all 
stages  of  the  treatment  of  the  malady  under  consideration.  It  cannot  be 
effected  by  means  of  the  suspensory  bandage.  Such  a  bandage  lets  the 
testicle  drop  between  the  thighs,  and,  although  it  is  useful  in  the  erect 
posture,  it  loses  its  value  entirely  when  the  patient  lies  down. 

An  excellent  means  of  suspending  the  testicles  is  that  employed  in 
most  hospitals.  It  is  quite  effective,  but  is  unfortunately  dirty.  It  con- 
sists simply  in  cutting  a  strip  of  ordinary  adhesive  plaster,  four  or  five 
inches  broad  and  long  enough  to  stretch  from  one  side  to  the  other  over 
the  tops  of  the  two  thighs,  just  beneath  the  scrotum,  as  the  patient  is 
lying  down.  A  crescentic  piece  should  be  cut  out  of  the  plaster  to  pre- 
vent it  from  cutting  the  root  of  the  scrotum.  It  is  applied  by  being 
fastened  securely  in  place,  the  adhesive  side  sticking  to  the  skin  on  the 
outer  aspect  of  both  thighs  as  they  lie  close  together,  the  scrotum  and  in- 
flamed testicle  meantime  having  been  drawn  well  up  out  of  the  way,  to 


102 


VENEREAL  DISEASES. 


be  afterward  gently  deposited  upon  the  tense,  smooth,  dry  table  formed 
between  the  thighs  by  the  non-adhesive  side  of  the  plaster  (Fig.  55). 

The  plaster  is  rather  dirty,  the  legs  are  constrained,  the  top  of  the 
plaster  sometimes  cuts  into  the  root  of  the  scrotum ;  but  the  bandage  does 
not  slip,  and  the  support  is  quite  efficient. 

Another  method  of  making  support,  and  one  which  applies  to  all 
cases  whether  or  not  poultices  or  other  dressings  are  to  be  used,  is  the 
following:  a  large  handkerchief— preferably  of  silk— is  to  be  folded  into 
a  triangle.  At  the  centre  of  the  base  of  this  double  triangle,  opposite 


FIG.  65.— Plaster  Support  for  Suspending  Testicle  in  Bed,  and  Elastic  Pressure. 


the  right  angle,  a  double  piece  of  tape,  about  three  feet  long,  is  to  be 
sewed.  An  ordinary  stiff  roller  bandage  is  drawn  quite  snugly  around 
the  waist  above  the  flare  of  the  pelvic  bones  and  secured  by  safety  -pius. 
Then  the  patient  is  instructed  to  hold  the  testicles  and  scrotum  well  up 
above  and  over  the  symphysis  pubis.  The  centre  of  the  long  side  of  the 
triangular  silk  handkerchief,  marked  by  the  tapes,  is  now  placed  in  the 
perineum  well  up  against  the  root  of  the  scrotum,  and  one  end  of  it  is 
carried  up  on  each  side  along  the  fold  of  the  groin  under  the  roller  band- 
age, after  which  both  these  ends  are  drawn  upon  so  as  to  make  the  long 
side  of  the  triangle  sufficiently  tense  under  the  scrotum,  and  fastened  into 
place  with  large  safety-pins.  Finally  the  two  tapes  are  carried  around 
the  thighs  on  either  side  and  under  the  roller  bandage,  where  they  are 
fastened  so  as  to  keep  the  perineal  portion  of  the  handkerchief  fixed. 
The  point  of  the  triangular  handkerchief  is  to  be  folded  over  and  loosely 


EPIDIDYMITIS.  103 

pinned  up  to  the  roller  bandage  in  front,  to  retain  in  place  any  dressing 
which  may  be  put  upon  the  testicle. 

Some  authorities  advise  ice,  and  its  application  is  very  simple.  It  is 
only  necessary  to  separate  the  thighs  and  place  the  inflamed  testicle  upon 
a  suitable  cushion,  after  which  broken  ice,  floating  in  its  own  water  con- 
tained in  a  rubber  or  oil-silk  bag  of  ample  size,  is  placed  upon  the  testicle 
and  cushion.  Ice  is  useful  in  intense  neuralgia  of  the  testicle,  but  use- 
less if  not  harmful  in  most  inflammatory  conditions. 

By  way  of  internal  medication  the  following  combination  may  be 
given : 

IJ  Tinct.  phytolacca  decandra, gtt.  x.-xxx. 

lodine-vasogen  (6  per  cent), gtt.  xv. 

Given  in  milk  three  times  daily  after  meals. 

The  former  drug  is  intended  to  lower  arterial  tension  in  the  inflamed  organ 
and  the  iodine  to  assist  in  the  removal  of  the  fluid  contents  of  the  tunica 
vaginalis.  This  special  preparation  of  iodine  consists  of  free  iodine  in  a 
hydrocarbon  oil,  and  is  absorbed  by  the  system  with  marked  activity. 

Numerous  internal  remedies  have  been  at  various  times  advocated  in 
the  treatment  of  epididymitis.  None  of  them  has  held  place.  The 
continued  nauseant  influence  of  frequently  repeated  small  doses  of  tartar 
emetic  has  proved  of  no  value.  Pulsatilla  has  been  loudly  vaunted, 
splendid  effects  being  claimed  for  it  in  doses  of  one-tenth  of  a  minim 
often  repeated  up  to  one  drop  three  times  a  day.  It  has  failed  in  most 
hands,  employed  either  to  check  the  pain  or  to  modify  the  course  of  the 
malady.  It  is  well  to  correct  the  strong  tendency  to  constipation  which 
generally  exists  in  the  disease  by  the  daily  use  of  gentle  laxatives ;  and 
on  the  few  occasions  when  the  pains  demand  it,  there  is  no  objection  to 
the  administration  of  a  small  amount  of  codeine  or  other  gentle  anodyne. 

Leeches  upon  the  scrotum  do  not  afford  any  considerable  relief  and 
their  use  is  attended  by  obvious  disadvantages.  When  the  testicle  seems 
to  be  strangulated  by  the  intensity  of  the  inflammation,  a  large  number  of 
leeches — ten  to  twenty — placed  over  the  upper  part  of  the  scrotum  and 
along  the  course  of  the  cord,  will  sometimes  afford  relief  from  the  imme- 
diate and  excruciating  pain ;  but  puncture  of  the  tunica  vaginalis  will 
afford  similar  relief  and  is  to  be  preferred. 

In  all  acute  cases  of  epididymitis  there  is  more  or  less  effusion  of 
serum  into  the  cavity  of  the  tunica  vaginalis,  making  an  acute  hydrocele, 
the  size  of  which  is  sometimes  considerable,  generally  unimportant. 
"When  the  tension  within  the  testicle  is  great  and  the  effusion  consider- 
able, relief  may  sometimes  be  promptly  afforded  the  patient  by  resorting 
to  puncture  of  the  tunica  vaginalis.  A  number  of  punctures  may  be  made 
subcutaneously  with  a  fine,  sharp-pointed  knife,  so  that  the  fluid  may 
escape  into  the  meshes  of  the  connective  tissue  of  the  scrotum,  or  the 


1Q4  VENEREAL  DISEASES. 

serum  may  be  drawn  off  by  aspiration.  After  aspiration  the  cavity  may  re- 
fill, but  often  the  acuteness  of  the  pain  subsides  after  a  single  puncture,  and 
the  subsequent  collection  of  fluid  may  be  disregarded.  When  the  tunic  is 
not  distended,  its  puncture  does  not  afford  relief — as  might  be  inferred. 

This  operation  is  entirely  devoid  of  any  risk  or  danger,  and  is  justi- 
fiable under  all  circumstances  of  distention  of  the  tunica  vaginalis  in 
connection  with  acute  inflammatory  disease. 

The  sheet  anchor  of  treatment  in  epididymitis,  however,  is  the  local 
use  of  hot  fomentations  or  poultices.  Belladonna  and  opium  in  different 
forms,  as  hot  decoctions  and  infusions,  have  been  employed,  but  they 
possess  no  advantage  over  tobacco  and  flaxseed.  Tobacco  is  undoubtedly 
a  filthy  substance,  but  it  may  be  so  managed  that  the  patient  is  little,  if 
at  all,  soiled  by  it.  Excoriations  of  large  size  upon  the  skin  of  the 
scrotum  contraindicate  the  use  of  any  narcotic  or  anodyne  in  the  poul- 
tices, which  must  then  be  composed  of  some  simple  material. 

To  make  a  tobacco  poultice  which  shall  be  at  once  efficient  and  clean 
the  following  course  may  be  followed :  one  ounce  (a  paper,  as  ordinarily 
sold  for  chewing)  of  fine-cut  tobacco  is  to  be  finely  shredded  into  a  tin 
or  earthen  vessel  containing  from  eight  to  ten  ounces  of  boiling  water. 
Into  this  is  put  a  tablespoon ful  of  glycerin  or  of  sweet  oil,  and  into  the 
whole,  while  being  rapidly  stirred,  is  mixed  a  powder  of  equal  parts  of 
ground  elm  bark  and  ground  flaxseed,  in  sufficient  quantity  to  bring  the 
whole  mass  to  the  proper  consistence  for  a  soft  poultice.  Some  patients 
manifest  disagreeable  sensations  due  to  the  effect  of  tobacco  absorption, 
in  which  case  the  latter  should  be  removed  from  the  poultice. 

Plain  flaxseed  poultices  may  also  be  used  in  place  of  the  tobacco  com- 
bination. 

Whatever  is  used  should  be  placed  between  two  layers  of  cheese-cloth, 
and  after  being  put  around  the  testicle,  should  be  surrounded  by  absorbent 
cotton  to  help  retain  the  heat,  and  covered  over  with  a  piece  of  oil  silk 
to  protect  the  bed  clothing. 

The  poultice  when  made  should  be  perfectly  moist,  soft,  and  smooth, 
•  but  should  not  drip.  It  should  be  large  enough  to  cover  the  entire  tes- 
ticle—indeed, the  whole  scrotum.  It  must  be  applied  as  hot  as  it  can  be 
borne  and  renewed  every  one  or  two  hours. 

It  is  well  in  all  cases  bad  enough  to  confine  the  patient  to  bed  that 
the  poultice  should  be  applied  at  once  as  soon  as  the  testicle  is  suspended. 
It  often  succeeds  in  relieving  the  testicle  within  a  few  hours  and  in  entire- 
ly o  -ercoraing  the  pain.  In  all  very  acute  or  intense  cases,  however,  this 
effect  cannot  be  expected  before  the  lapse  of  two  or  three  days,  possibly 
longer. 

The  vast  majority  of  cases  of  epididymitis  call  for  no  further  treat- 

aent  during  the  acute  stage  than  the  simple  means  already  enumerated: 

mild  laxatives,  an  elevated  position  of  the  testicle  with  the  patient  upon 


EPIDIDYMITIS.  105 

his  back,  and  the  continuous  use  of  poultices.  Under  these  means  the 
acute  symptoms  pass  off  in  a  period  varying  from  a  few  hours  in  inild 
cases  to  a  few  days,  all  pain  disappearing  at  the  very  outside  in  two 
weeks  in  the  worst  cases.  Generally  the  patient  who  lies  down  at  once, 
even  with  a  very  severe  first  attack  of  the  disease  (which  is  the  worst  he 
can  have),  may  be  assured  that  he  will  be  cut  and  attending  to  his  busi- 
ness in  ten  days,  and  this  period  under  good  management  may  often  be 
shortened  to  a  week,  while  cases  which  last  only  from  twenty-four  hours 
to  three  days  are  by  no  means  uncommon. 

When  the  acute  symptoms  subside,  however,  the  patient  is  not  well. 
The  pain  usually  subsides  entirely  in  from  one  to  three,  or  possibly  five 
or  six  days;  but  long  after  the  patient  ceases  to  feel  pain  the  swelling 


FIG.  56. 

remains,  and  the  dragging  upon  the  cord  by  the  weight  of  the  testicle  in 
the  erect  position  brings  on  acute  pain.  It  is  at  this  stage  that  properly 
applied  pressure  renders  distinct  service  in  reducing  the  swelling  and 
lessening  the  tenderness  of  the  organ. 

Should  a  patient  find  it  necessary  to  leave  his  bed  before  completing 
his  week  or  ten  days,  and  not  be  able  to  wait  until  he  can  stand  erect  for 
fifteen  minutes  without  pain,  he  may  do  so  by  the  aid  of  strapping  or 
elastic  compression.  Just  as  soon  as  the  acute  symptoms  are  fairly  on 
the  decline  and  the  testicle  can  be  handled,  even  although  it  be  with 
pain,  the  patient  may  get  up  and  go  about  with  safety,  so  far  as  relapse 
is  concerned,  if  the  testicle  be  properly  strapped.  The  first  straps  should 
be  put  on  with  great  gentleness  and  not  too  tightly.  The  patient  must 
be  directed  to  stay  in  bed,  and  to  remove  the  straps  or  to  cut  them  down 
the  front,  if  the  testicle  be  not  quite  comfortable  in  half  an  hour  after 
the  straps  have  been  applied. 

The  straps  composed  of  rubber  plaster  are  required  to  be  carefully 
applied  and  sometimes  cause  trouble  in  being  removed,  it  being  necessary 
to  soak  them  off  in  hot  water  if  the  plaster  is  very  adherent.  Another 
method  of  obtaining  the  benefit  of  compression  of  the  swollen  testicle  after 
the  tenderness  has  subsided,  and  one  which  is  equally  satisfactory  and 
much  less  troublesome,  is  elastic  pressure  procured  with  a  section  of  a 
rubber  elastic  bandage  about  three  inches  wide  and  six  to  seven  inches 
long.  Attached  to  one  end  of  this  is  a  narrow  strip  of  rubber  adhesive 
plaster  about  one-half  inch  wide  and  long  enough  to  go  once  around  the 


106  VENEREAL  DISEASES. 

testicle  and  overlap.  This  plaster  is  intended  to  hold  the  rubber  bandage  in 
place  after  it  has  been  applied  (Fig.  56) .  This  is  accomplished  as  follows : 
The  swollen  testicle  is  pulled  down  slightly  and  the  sound  one  is  pushed 
upward  against  its  ring ;  the  free  end  of  the  rubber  bandage  is  applied  to 
the  surface  of  the  organ  and  the  rest  is  used  to  encircle  it,  being  applied 
with  sufficient  tension  to  procure  moderate  pressure.  The  bandage  is 
finally  held  in  place  by  wrapping  around  it  the  rubber  adhesive  strip 
(Fig.  55).  The  even  elastic  pressure  thus  attained  acts  most  promptly 
upon  the  swelling  and  never  produces  any  trouble.  The  bandage 
tends  to  contract  with  the  testicle,  and  may  be  readjusted  when  neces- 
sary. By  the  use  of  such  means  of  compression  the  acute  stage  of  the 
attack  is  liable  to  be  shortened  and  the  patient  likely  to  get  about  sooner 
than  without  this  expedient.  In  cases  in  which  the  testicle  will  stand 
the  pressure  without  undue  pai:-,  it  may  be  applied  while  the  patient  is 
still  confined  to  bed,  in  conjunction  with  the  poultices,  and  thus  curtail  the 
duration  of  the  attack. 

Chronic  relapsing  epididymitis  may  be  treated  by  vasectomy  (ligation 
of  the  vas  deferens)  on  the  affected  side.  The  authors  have  performed 
this  operation  in  a  number  of  instances,  with  the  result  of  a  permanent 
cure  in  every  case.  One  case  was  bilateral  and  had  double  hydrocele. 

The  operation  is  simple,  and  may  be  done  over  the  external  ring  or 
in  the  median  raphe  of  the  scrotum ;  in  either  of  which  locations  the  cord 
is  readily  found,  the  vas  deferens  separated,  and  a  small  piece,  about 
one-fourth  of  an  inch,  resected  between  two  ligatures. 


CHAPTER  VI. 

STEICTUKE   OF  THE   URETHRA. 

A  COMMON  consequence  of  gonorrhoea  in  the  male  is  stricture  of  the 
urethra.  True  stricture,  a  narrowing  of  the  calibre  of  the  canal,  the  re- 
sult of  inflammatory  exudation  and  cicatricial  contraction,  also  may  be 
due  to  other  causes,  such  as  traumatic  violence  of  any  sort,  mechanical  or 
chemical.  Congenital  imperfection  of  the  urethra,  more  common  at  the 
meatus,  producing  a  constriction  of  the  canal,  has  been  called  "  congenital 
stricture."  It  differs  from  true  stricture  in  that  it  does  not  contract,  but 
remains  as  congenitally  formed.  It  therefore  might  be  termed  for  dis- 
tinction congenital  stenosis.  The  term  "acquired  stricture"  embraces 
the  various  other  forms,  such  as  organic,  traumatic,  spasmodic,  and  in- 
flammatory. Organic  stricture  occurs  as  a  result  of  acute  inflammation 
of  or  injury  to  the  canal,  and  represents  what  is  meant  by  true  stricture. 

Traumatic  stricture  is  included  in  the  previous  classification,  but  is  of 
non-venereal  origin. 

The  term  "  inflammatory  stricture "  denotes  a  constriction  produced 
by  soft  inflammatory  cellular  infiltration,  which  may  be  absorbed  or  may 
go  on  to  form  true  fibrotic  stricture.  It  also  signifies  simple  inflamma- 
tory, oedematous,  and  congestive  swelling  enough  to  diminish  the  calibre 
of  the  canal.  This  is  in  no  sense  a  true  stricture. 

SPASMODIC  STBICTTJRE. 

"  Spasmodic  stricture  "  may  depend  upon  a  multitude  of  causes,  gen- 
eral as  well  as  local,  moral  as  well  as  physical.  Moreover,  it  may  com- 
plicate the  other  forms  of  stricture  of  the  canal  and  give  to  them  an  im- 
portance which  they  would  not  otherwise  possess.  Spasmodic  action  of 
the  muscles  of  the  deep  urethra  produces  an  obstruction  which  may  result 
in  retention  of  urine ;  but  as  the  cause  may  exist  outside  the  urethra,  being 
reflex,  and  as  this  condition  sometimes  coexists  with  true  stricture,  it  is 
more  properly  designated  urethral  spasm. 

Urethral  spasm  or  "  spasmodic  stricture  "  is  generally  capable  of  very 
easy  demonstration.  A  personal  case  will  well  illustrate  this. 

A  young  man,  under  twenty  years  of  age  and  perfectly  healthy  so  far 
as  urethral  or  antecedent  venereal  disease  of  any  kind  was  concerned, 
finding  some  pediculi  upon  his  pubes,  was  kindly  supplied  with  a  lotion 
by  an  obliging  friend  with  which  to  kill  them.  This  he  applied  faithfully 


103  VENEREAL  DISEASES. 

in  the  morning.  The  lotion,  which  was  a  simple  tincture  of  delphinium, 
proved  quite  irritating,  and  presently  occasioned  much  tingling  and 
burning  of  the  skin  where  it  had  been  applied,  and  brought  on  a  desire 
to  urinate ;  but  the  patient,  to  his  surprise,  found  that  he  could  not  void 
a  drop  of  urine,  the  bladder  being  only  slightly  distended. 

He  continued  up  and  about  all  day,  making  repeated  but  absolutely 
futile  efforts  to  empty  his  bladder,  and  finally  sought  relief  late  in  the 
afternoon,  when  a  full-sized  olivary  soft  catheter  was  readily  passed  into 
the  bladder,  encountering  no  obstacle,  and  a  clear,  bright  stream  of  urine 
gushed  out  in  torrents  through  the  instrument  to  the  amount  of  more 
than  a  pint. 

The  patient  passed  water  voluntarily  in  the  evening  before  retiring, 
and  has  had  no  further  trouble. 

This  case  was  certainly  one  of  spasmodic  contraction  of  the  muscles 
of  the  deep  urethra,  due  to  irritation  reflected  from  the  skin.  There  was 
no  present  or  past  malady  of  the  bladder  or  urethra,  and  has  been  none 
since.  Efforts  were  made  in  vain  by  the  patient  to  empty  his  bladder 
during  all  stages  of  fulness.  There  was  not  a  particle  of  atony  in  the 
case,  for,  as  soon  as  the  urine  found  a  hole  from  which  to  escape,  it 
gushed  forth  under  the  powerful  contraction  of  the  detrusor,  and  did 
not  dribble  away  sluggishly  from  the  end  of  the  catheter,  as  it  is  wont  to 
do  in  cases  of  atony,  unless  aided  by  the  efforts  of  the  abdominal  muscles. 
The  stream  in  this  case  continued  with  equal  force  and  vigor  up  to  the 
last  few  drops.  Here,  then,  is  a  case  of  pure  reflex  spasm  of  the  urethra. 

In  February,  1896,  a  patient  called  upon  the  authors,  having  had  sev- 
eral attacks  of  complete  retention  of  urine.  He  had  reached  the  age  for 
prostatic  hypertrophy,  and  had  been  told  that  such  was  the  cause  of  his 
trouble.  Indeed  he  had  just  come  away  from  a  Brooklyn  hospital  because 
orchidectomy  had  been  proposed,  which  he  had  rejected.  Examination 
revealed  that  there  was  no  undue  frequency  of  urination  by  day,  nor  even 
at  night;  that  the  bladder  emptied  itself  completely,  and  that  each  attack 
of  retention  had  been  relieved  instantaneously  by  the  single  passage  of  a 
catheter,  and  was  separated  by  a  long  interval  from  each  previous  attack. 
Exploration  of  the  urethra  demonstrated  the  existence  of  a  true  organic 
stricture,  but  one  which  was  quite  permeable.  The  prostate  was  practi- 
cally normal.  The  retention  of  urine  had  been  caused  by  spasmodic 
contraction  of  the  deep  urethral  muscles — urethral  spasm— complicating 
true  organic  stricture. 

Tuffnell  reports  a  case  in  which  a  patient  had  a  stricture  deemed  im- 
passable (doubtless  because  fine  bougies  only  were  used  in  attempts  to  pass 
*).  This  patient  suffered  so  much  that  a  day  was  appointed  upon  which 
perineal  section  should  be  performed;  but  before  the  date  arrived  he 
passed  some  links  of  tapeworm,  unsuspected  before,  and,  as  a  part  of 

e  preparation  for  his  operation,  a  medicine  was  given  to  dislodge 
the  worm.  This  proved  successful.  The  worm  was  passed,  and  with  it 


STRICTURE   OF   THE   URETHRA.  109 

the  impassable  stricture  disappeared,  and  the  patient  urinated  freely  at 
will. 

It  has  occurred  several  times  in  our  experience  for  a  surgeon  to 
make  a  diagnosis  of  tight  stricture  in  a  given  case,  and  to  find  his  fili- 
form bougie — which  he  has  passed  with  difficulty — grasped,  as  he 
attempted  to  withdraw  it,  when  there  has  been  nothing  more  in  the  case 
than  spasmodic  contraction  of  the  deep  urethra,  as  proved  by  the  fact 
that  a  well-warmed,  large,  blunt  steel  sound,  held  gently  against  the  face 
of  the  obstacle,  has  after  a  short  delay,  slipped,  by  its  own  weight, 
smoothly  into  the  bladder. 

Eegarding  the  location  of  urethral  spasm  it  is  probably  found  only  in 
the  membranous  portion;  and  although  some  authors  have  claimed  its 
existence  in  the  anterior  canal,  Guyon  has  demonstrated  by  the  applica- 
tion of  the  electric  current  that  no  spasmodic  contraction  of  this  region 
occurs.  In  some  cases  it  is  quite  difficult  to  distinguish  between  urethral 
spasm  and  a  stricture  situated  at  the  bulbo-membranous  junction.  The 
resistance  of  the  latter  is  firm,  tense,  abrupt,  as  contrasted  with  the  mus- 
cular contraction  which  is  softer,  more  yielding,  and  elastic. 

If  a  blunt  steel  instrument  be  held  firmly  against  the  face  of  a  "  spas- 
modic stricture  "  with  gentle  but  persistent  pressure,  the  contraction  often 
yields  suddenly  and  the  instrument  enters,  causing  a  certain  amount  of 
pain ;  but  in  the  case  of  true  stricture  the  resistance  is  firm  and  unyield- 
ing, and  is  not  suddenly  overcome  by  the  gentle  force  of  an  instrument 
larger  than  the  calibre  of  the  stricture. 

The  attendant  symptoms  will  render  additional  assistance  in  dis- 
tinguishing between  these  two  conditions.  In  the  case  Of  urethral 
spasm  the  evidence  of  urinary  obstruction  is  of  an  irregula*  character. 
Sometimes  the  difficulty  lies  at  the  commencement  of  urination,  while  the 
continuation  of  the  act  is  normal.  Again,  an  effort  is  required  to  pass  the 
water  during  the  entire  act,  or  the  stream  may  be  abruptly  interrupted 
before  the  bladder  is  emptied ;  while  in  other  cases  partial  or  complete 
retention  may  occur.  The  presence  of  urethral  spasm  is  clearly  demon- 
strated when  the  functional  difficulty  is  not  constant  but  variable,  and 
an  attempt  to  pass  a  small  bougie  is  unsuccessful.  An  organic  obstacle, 
if  small  enough  to  obstruct  the  bougie,  would  yield  constant  symptoms. 
When  even  the  smallest  instrument  will  not  pass  in  the  case  of  spasm,  a 
very  large  blunt  steel  sound  will  sometimes  enter  without  hesitation  or 
delay. 

The  causes  of  urethral  spasm  are  direct  and  indirect.  Who  is  un- 
familiar with  the  effect  of  shame,  haste,  anxiety,  anger,  nervous  ex- 
citability, and  other  emotions  in  making  it  absolutely  impossible  for  a 
perfectly  healthy  patient  sometime  ?  to  void  water  at  all  for  a  consider- 
able time?  Such  retention  is  due  to  a  spasm  of  the  urethra.  Of  the 
various  local  causes  of  "  spasmodic  stricture  "  may  be  mentioned  cystitis 


HQ  VENEREAL  DISEASES. 

of  the  neck  of  the  bladder,  posterior  urethritis,  stone  in  the  bladder, 
irritation  about  the  rectum,  and  trouble  in  the  anterior  urethra,  acute 
inflammation,  organic  stricture,  and  contracted  meatus.  The  grasping 
of  a  sound  by  an  organic  stricture,  through  which  the  instrument  has 
been  passed,  is  due  to  spasm.  The  lack  of  co-ordination  between 
the  detrusor  and  the  cut-off  muscles,  often  leading  to  retention  in 
cases  of  locomotor  ataxia  and  partial  paraplegia  (especially  syphilitic), 
acts  apparently  by  causing  spasm  of  the  deep  urethral  muscles.  The 
different  conditions  in  which  deep  organic  stricture  habitually  finds  itself 

sometimes  allowing  a  reasonably  free  stream  of  urine  to  pass,  again  so 

nearly  closed  up  that  only  a  few  drops  can  be  painfully  voided  with  great 
effort — are  undoubtedly  due  more  often  to  spasm  than  to  any  purely  in- 
flammatory change  in  the  stricture  itself.  That  form  of  partial  or  com- 
plete retention  sometimes  seen  in  connection  with  a  very  slight  stricture  of 
large  calibre,  either  in  the  deep  or  in  the  pendulous  urethra,  is  certainly 
due  to  spasm  of  the  membranous  sphincter,  as  proved  by  the  ease  with 
which  many  of  these  cases  allow  the  passage  of  a  large-sized  steel  in- 
strument without  the  employment  of  any  force. 

Treatment. — The  surgeon's  tact  and  ability  are  often  taxed  to  dis- 
cover the  cause  of  deep  urethral  irritability  and  spasm.  To  be  successful 
in  his  treatment  he  must  find  the  cause ;  when  that  is  removed  the  "  stric- 
ture "  will  get  well.  The  cause  may  lie  in  a  tight  meatus,  or  in  an  irri- 
table anterior  or  posterior  stricture  of  large  or  small  calibre,  which  will 
require  appropriate  treatment. 

Sometimes  the  passage  of  a  large-size  catheter  or  a  well-oiled  sound 
will  result  in  the  instant  relief  of  the  difficulty,  and  the  same  result  may 
be  brought  about  by  means  of  a  hot  sitz-bath. 

ORGANIC  STRICTURE. 

Etiology  and  Location. — Most  cases  of  organic  stricture  owe  their 
origin  to  gonorrhoea,  and  it  is  that  form  which  is  commonly  referred  to 
in  speaking  of  stricture  of  the  urethra.  Injury  to  the  urethra  resulting 
in  complete  rupture  of  the  canal,  or  lacerations  and  abrasions  of  a  lesser 
degree,  blows  or  falls  upon  the  perineum,  forcible  bending  of  the  penis 
during  erection,  may  all  be  followed  by  the  production  of  organic 
stricture. 

When  stricture  of  the  urethra  results  from  gonorrhoea  it  is  due  rather 
to  a  long-continued  inflammatory  process  than  to  an  inflammation  intense 
in  character  but  short  in  duration.  The  development  of  stricture  is 
generally  slow.  It  is  seldom  encountered  much  before  the  second  year 
following  gonorrhoea,  although  there  are  marked  exceptions.  The  growth 

stricture  is  also  dependent  upon  the  nature  of  the  original  lesion.     In  f 
traumatic  stricture  the  period  is  shorter  than  that  following  inflammation 


STRICTURE   OF   THE   URETHRA.  Ill 

of  the  canal.  Sir  Henry  Thompson,  from  an  observation  of  164  cases, 
found  that  about  one-sixteenth  of  this  number  had  developed  in  less  than 
one  year  from,  the  urethritis,  about  three-fourths  of  this  number  between 
one  and  four  years  afterward,  and  that  the  balance  was  equally  divided 
between  periods  of  seven  and  eight  years  and  over  twenty  years.1  Guyon 
finds  from  an  observation  of  142  cases  the  following  order  of  frequency : 
During  the  first  year,  4 ;  from  first  to  second  year,  10 ;  second  to  fourth 
year,  20;  fourth  to  sixth  year,  19;  sixth  to  eighth  year,  24;  eighth 
to  tenth  year,  16;  tenth  to  fifteenth  year,  49.  Thus  it  appears  that  in 
a  majority  of  instances  stricture  in  his  experience  is  detected  between  two 
and  ten  years  after  the  original  inflammation. 

Stricture  may  occur  at  any  age,  is  seldom  found  in  very  old  men,  and 
is  most  common  between  the  ages  of  thirty  and  forty. 

Eegarding  the  most  common  location  of  stricture  Taylor,2  in  a  classi- 
fication of  250  personal  cases,  finds  62  per  cent  in  the  sinus  of  the  bulb, 
20  per  cent  in  the  middle  of  the  pendulous  urethra,  and  18  per  cent  in 
front  of  the  latter  region.  These  may  be  designated  regions  one,  two, 
and  three,  from  behind  forward. 

Taylor's  tabulation  is  simply  a  ratification  of  Sir  Henry  Thompson's 
observations.  Thus  it  may  be  roughly  stated  that  over  sixty  per  cent  of 
cases  of  stricture  exist  in  the  region  lying  between  the  bulbo-membranous 
junction  and  the  peno-scrotal  angle,  and  that  the  remaining  cases  are 
about  equally  distributed  throughout  the  rest  of  the  anterior  canal. 

Stricture  of  the  prostatic  urethra  does  not  occur  as  a  result  of  gonor- 
rhoeal  inflammation.  The  best  observers  also  state  that  stricture  of  the 
membranous  urethra  does  not  occur  from  the  same  cause,  but  that  this 
portion  of  the  canal  is  more  apt  to  be  dilated,  as  well  as  the  prostatic 
portion  behind  an  organic  stricture  involving  the  section  of  the  urethra 
anterior  to  them. 

In  examining  the  urethra  according  to  the  divisions  specified,  it  has 
been  found  by  many  observers  that  in  the  majority  of  cases  only  one 
region  is  involved.  In  some  instances  the  stricture  invades  the  two  re- 
gions in  front  of  the  peno-scrotal  angle  (Fig.  57)  or  the  two  consecutive 
regions  between  the  bulbo-membranous  junction  and  a  point  two  and 
one-half  inches  from  the  meatus,  but  only  exceptionally  does  stricture 
occur  near  the  meatus  in  conjunction  with  stricture  in  the  bulbous 
urethra  without  involving  the  intermediate  portion.  Such  records  seem 
to  show  that  a  single  stricture  is  the  rule  and  that  multiple  stricture  is 
the  exception.  Other  observers  claim  the  opposite  of  this  rule;  but  with 
the  present  knowledge  of  the  pathological  formation  of  stricture  tissue, 
it  can  be  understood  how  in  exploring  the  urethra  the  conclusion  that 
multiple  stricture  existed  might  be  reached,  from  the  fact  that  an  exten- 

1  Desnos :  "  Traits'  elementaire  des  Maladies  des  Voies  urinaires." 

2  "Venereal  Disease,"  1895. 


112 


VENEREAL  DISEASES. 


sive  area  infiltrated  with  fibrous  tissue  must  vary  at  different  points  in 
the  degree  of  the  existing  stenosis  (Fig.  57) .  In  other  words,  a  stricture 
commencing  in  any  part  of  the  spongy  urethra  may  reach  the  maximum 


FIG.  57.  —  Annular  Stricture  of  the  Anterior  FIG.  58.— Linear  Stricture. 

Urethra  covering  an  Extensive  Area. 

degree  of  contraction  at  the  bulbo-membranous  junction ;  or,  on  the  other 
hand,  on  account  of  an  increase  of  deposit  of  cicatricial  tissue  at  one  or 
more  points  anterior  to  the  bulb,  the  exploring  instrument  would  detect 
what  seemed  to  be  more  than  one  strictured  point. 


STRICTURE   OF   THE   URETHRA. 


113 


The  formation  of  stricture  is  variable,  and  depends  upon  the  character 
and  extent  of  the  pathological  changes  in  the  course  of  the  canal.  Thus, 
when  there  exists  an  infiltration  of  the  connective  tissue  sufficiently  dense 
to  cause  a  stenosis  of  the  calibre,  but  before  fibrous  tissue  has  been 
formed,  such  a  condition 
is  spoken  of  as  soft  strict- 
ure. When  the  fibrous 
element  has  sufficiently 
invaded  the  softer  struct- 
ure at  the  further  expense 
of  the  normal  tissue,  the 
lesion  is  called  a 


semi- 
fibrous  of  fibrous  stricture 
according  to  the  degree 
of  thickening.  Finally, 
when  this  process  ex- 
tends itself  still  farther 
so  that  the  normal  tissues 
are  entirely  obliterated 
and  sclerotic  and  atrophic 
changes  occur,  yielding  a 
firm  and  indurated 
structure,  the  so-called 
inodular  stricture  is  the 
result. 

These  pathological 
changes,  as  they  involve 
greater  or  less  areas  of  the 
canal,  and  are  accompa- 
nied by  more  or  less  ste- 
nosis in  different  portions, 
represent  the  various 
types  of  stricture  under 
the  different  clinical  ap- 
pellations. Thus  a  linear 
stricture  is  a  band  of 
fibrous  thickening  with  a 
maximum  narrowing  at 
one  point  (Fig.  58);  an- 
nular stricture,  the  same 

condition  covering  a  broader  surface,  sometimes  involving  several  inches 
of  the  canal  (Fig.  57),  while  an  extensive  distribution  of  the  nodular  tissue 
around  an  irregular  channel  results  in  what  is  called  inodular  or  tortuous 
stricture  (Fig.  59). 


FIG.  59. — Inodular  or  Tortuous  Stricture. 


VENEREAL  DISEASES. 

For  purposes  of  classification  it  is  customary  also  to  divide  strictures 
with  regard  to  the  degree  of  stenosis  into  strictures  of  large  and  small 
calibre.  Such  a  distinction  is  of  course  simply  an  arbitrary  one  and  is 
governed  by  no  established  standard.  It  is  generally  understood  that  a 
stricture  which  will  permit  the  introduction  of  an  instrument  5  mm.  in 
diameter  (15  French)  or  larger  may  be  considered  one  of  large  calibre, 
while  anything  below  this  is  regarded  as  of  small  calibration. 

In  order  to  determine  whether  or  not  the  urethra  is  the  seat  of  a  nar- 
rowing such  as  should  properly  come  under  the  title  of  stricture  it  is  bet- 
ter to  have  in  mind  a  popular  standard  for  the  normal  urethra  to  compare 
with.  Any  pronounced  variation  below  the  natural  calibre  must  be  con- 
sidered a  "  stricture  of  the  urethra.  "  It  is  important,  however,  in  deter- 
mining the  natural  calibre  of  the  urethra  to  bear  in  mind  that  there 
normally  exist  anatomical  points  of  narrowing,  and  that  between  these 
anatomical  points  the  urethra  may  be  dilated  beyond  what  should  be 
regarded  as  its  normal  calibre  (Fig.  60). 

The  objection  to  the  division  of  strictures  into  those  of  small  and 
large  calibre  is  that  unless  the  standard  be  placed  at  a  reasonable  size 
strictures  of  large  calibre  will  undoubtedly  oftentimes  be  discovered  at 
one  of  the  points  of  physiological  narrowing.  The  objection  is  properly 
raised  to  the  scale  given  by  Otis,  which  recognizes  a  definite  relation  be- 
tween the  circumference  of  the  penis  and  the  calibre  of  the  urethra,  that 
it  is  too  dogmatic  and  represents  more  accurately  the  distensibility  of 
the  urethra  than  its  normal  calibre. 

The  scale  adopted  by  Otis  is  shown  in  the  following  table  :' 

TABLE  SHOWING  THE  RELATIVE  CIRCUMFERENCE  OF  THE  PENIS  AND  URETHRA. 


Circumference  Circumference 

of  Penis.  of  Urethra. 

3    inches,  or  43  mm.  30  mm. 

3i       «      «  81."  32     " 

3J       "      "  87    «  84     " 


Circumference  Circumference 

of  Penis.  of  Urethra. 

3f  inches,  or   93  mm.  36  mm. 

4        "       «   100    "  38     " 
4£  to  4£  inches,  or  106  to 

112mm  ..............  40     " 

In  employing  the  above  scale  for  estimating  the  normal  calibre  of  the 
urethra  Dr.  Otis  has  devised  and  recommends  the  urethrometer,  an  in- 
strument for  exploratory  purposes,  having  a  hinged  extremity  which  can 
be  expanded  to  a  bulbous  shape  between  sizes  20  and  45  French  (Fig. 
66,  p.  121),  but  when  any  urethra  is  explored  with  this  instrument  and  in 
accordance  with  the  above  table  it  is  hardly  possible  that  it  will  be  found 
free  from  some  variation  in  its  calibre  and  therefore  will  be  considered  as 
the  seat  of  stricture,  a  conclusion  the  acceptance  of  which  must  lead  to  a 
most  indiscriminate  and  unnecessary  interference  either  by  cutting  or  by 
overdistention.  A  conservative  estimate  of  the  average  size  of  the  canal 
in  the  majority  of  cases  places  the  normal  calibre  at  about  28  or  30  French, 

1  Otis:  "Stricture  of  the  Urethra." 


STRICTURE   OF  THE   URETHRA. 


115 


and  while  exceptionally  it  may  be  somewhat  above  or  below  such  a  stand- 
ard, the  greatest  satisfaction  has  been  attained  by  those  observers  whose 
experience  permits  them  to  express  an  authoritative  opinion  in  the  accept- 
ance of  this  standard  both  for  exploring  the  urethra  and  in  the  treatment 
of  stricture. 

The  meatus  externally  and  inside  the  orifice  is  the  most  commonly 
constricted  point  and  is  subject  to  considerable  variation.  It  is  here  that 
congenital  narrowing  is  so  prone  to  exist  that  it  has  led  to  the  expression 
of  "congenital  stricture."  The 
meatus  is  sometimes  found 
sealed  up  to  the  size  of  a  pin- 
head,  livid  in  color  and  conical 
in  shape,  manifestly  unnatural, 
and  from  this  size  upward  it  is 
found  of  all  sizes,  sometimes 
altogether  disproportionately 
large  as  compared  with  the  rest 
of  the  canal.  This  smallness, 
which  is  a  congenital  deformity 
and  not  a  pathological  condition, 
never  calls  for  interference  on 
the  part  of  the  surgeon  unless  it 
be  presumed  to  be  the  probable 
cause  of  symptoms  such  as  re- 
flex spasm  of  the  membranous 
sphincter,  or  unless  it  interferes 
by  its  smallness  of  size  with  the 
proper  treatment  by  instruments 
of  morbid  conditions  more 
deeply  seated.  About  the  middle  of  the  spongy  portion,  from  two 
to  three  inches  from  the  meatus,  there  exists  in  a  large  percentage  of 
individuals  another  point  of  physiological  narrowing  which  is  often  des- 
ignated a  stricture  of  large  calibre  by  those  who  examine  the  urethra 
according  to  the  scale  of  Otis  and  with  the  idea  that  it  should  possess  a 
uniform  calibre  throughout  its  whole  course.  Behind  the  strictured  mea- 
tus we  have  a  dilated  area  known  as  the  fossa  navicularis.  Another 
dilated  cul-de-sac  exists  in  the  sinus  of  the  bulb,  in  front  of  the  triangu- 
lar ligament,  the  location  of  which  is  readily  recognized  by  the  introduc- 
tion and  withdrawal  of  an  instrument,  especially  a  bulbous  bougie,  and  at 
the  triangular  ligament  is  another  point  of  physiological  narrowing  which 
should  not  be  mistaken  for  stricture.  Besides  these  common  points  of 
constriction  and  dilatation  throughout  the  course  of  the  pendulous  ure- 
thra there  undoubtedly  exist  many  other  variations  from  the  maximum 
and  minimum  calibre,  so  that  in  exploring  the  urethra  the  larger  the 


FIG.  60.— A  Portion  of  a  Normal  Urethra  Distended 
with  Air,  showing  Transverse  Bands. 


VENEREAL  DISEASES. 

instrument  the  more  bands  does  it  discover  along  the  course  of  the  canal 
(Fig.  60).  Such  points  simply  represent  areas  of  uneven  disability  and 
will  exist  whether  such  an  individual  possesses  a  healthy  urethra  or  is 
the  subject  of  real  stricture;  whether  he  has  suffered  from  no  symptoms 
or  has  had  gleet;  whether  his  urethra  has  been  cut  internally  or  not,  and 
whether  or  not  his  symptoms  have  yielded  to  treatment.  Consequently 
the  existence  of  these  areas  in  the  anterior  portion  of  the  urethra  does  not 
constitute  stricture,  and  stricture  may  be  cured  while  the  areas  still  re- 
main behind. 

When  gonorrhoeal  stricture  occurs  it  has  been  pointed  out  by  patho- 
logical observers  that  it  generally  involves  the  urethra  over  a  large  area; 
that  there  may  be  points  at  which  exist  greater  degrees  of  contraction 
than  others  representing  several  of  the  transverse  folds  which  have  be- 
come infiltrated  and  consequently  impinge  on  the  calibre  of  the  canal  to 
a  greater  extent  than  the  intervening  portions.  Such  points  are  simply 
parts  of  .the  same  lesion  and  should  not  properly  be  counted  as  separate 
strictures. 

Traumatic  strictures  are  generally  limited  in  area  and  localized  in  one 
region,  according  to  the  seat  of  the  injury,  which  is  more  commonly  in 
the  bulbous  portion. 

.     Cicatricial  contraction  due  to  chancre  or  chancroid  usually  is  found 
near  the  meatus. 

SYMPTOMS. 

Strictures  of  wide  calibre  may  give  rise  to  spasmodic,  and  irritable 
troubles  in  the  deep  urethra.  When  they  do  so  act,  however,  they  are 
themselves  generally  more  or  less  sensitive  and  inflamed.  Sometimes, 
on  the  other  hand,  especially  at  the  meatus,  such  strictures  are  neither 
inflamed  nor  sensitive,  and  it  becomes  a  doubtful  question  to  decide 
whether  they  have  anything  to  do  with  troubles  deeper  in  the  canal  or 
not. 

The  vast  majority  of  these  strictures  produce  no  symptoms  whatso- 
ever, excepting  a  slight  gleet,  and  some  of  them  not  even  that.  Before 
deciding  that  a  given  tight  spot  in  the  urethra  is  the  cause  of  other  trou- 
ble deeper  in  the  canal,  it  is  wise  to  eliminate  all  other  sources  of  such 
trouble,  and  not  to  jump  at  the  conclusion  that  because  there  are  bands 
in  the  urethra,  and  spasmodic  or  inflammatory  trouble  farther  down,  the 
latter  necessarily  depends  upon  the  former,  and  will  be  relieved  by  a 
cutting  operation.  Such  a  doctrine  must  certainly  sooner  or  later  lead  the 
young  practitioner  to  the  border-line  of  quackery,  if  not  into  its  domain. 

The  most  common  symptom  of  strictures  of  large  calibre  in  the  pen- 
dulous or  in  the  deep  urethra,  is  a  gleety  discharge  more  or  less  purulent. 

As  stated  above,  stricture  of  large  calibre  may  go  for  a  long  time  un- 
discovered. Being  of  gonorrhoeal  origin  its  formation  is  usually  slow. 


STRICTURE   OF   THE   URETHRA.  117 

As  the  strictured  area  contracts,  the  patient  may  become  accustomed 
unconsciously  to  the  slight  effort  involved  during  the  act  of  urination 
and  may  fail  to  recognize  any  alteration  from  the  normal  state.  A 
period  is  sooner  or  later  reached  when  the  patient  becomes  conscious  of 
some  modification  either  in  the  size  or  the  shape  of  the  urinary  stream. 
This  may  be  twisted  or  it  may  be  uniformly  small  or  flattened  or  may  be 
expelled  in  two  separate  jets.  Such  changes  in  the  volume  and  form  of 
the  stream  are  not  invariably  significant  of  the  existence  of  true  stricture, 
as  they  may  be  noted  in  acute  and  chronic  urethritis,  in  prostatitis,  and 
in  urethral  spasm,  when  the  real  calibre  of  the  canal  is  determined  by  ex- 
ploration and  found  to  be  normal. 

Of  much  greater  importance  is  the  projectile  force  of  the  stream  dur- 
ing the  act  of  urination  as  an  index  of  the  tone  of  the  bladder  muscle; 
but  even  when  there  exists  a  marked  contraction  of  the  urethra  due  to 
stricture,  the  bladder  having  become  reinforced  by  compensatory  muscu- 
lar hypertrophy  may  eject  the  stream  from  the  urethra  with  reasonable 
force.  Soon,  however,  the  bladder  becomes  unable  to  compensate  for  the 
obstruction  in  the  canal,  the  stream  is  not  only  much  diminished  in  size 
but  ceases  to  be  projected  to  any  distance  from  the  end  of  the  penis  and 
either  falls  perpendicularly  in  a  small  stream  or  is  voided  by  drops  after 
considerable  effort  on  the  part  of  the  patient.  These  symptoms  denote 
tight  organic  stricture,  and  in  this  condition,  as  a  result  of  catching  cold 
or  from  the  effect  of  instrumental  examination,  congestion  of  the  surface 
of  the  stricture  or  reflex  spasm  of  the  compressor  urethrse  muscle  is  pro- 
duced, from  either  of  which  causes  the  passage  of  the  urethra  becomes 
occluded  and  urinary  retention  occurs. 

Urethral  discharge,  which  is  one  of  the  earliest  symptoms,  more  or 
less  muco-purulent  in  character,  is  generally  found  in  all  cases  of  stricture 
of  small  calibre,  but  it  may  be  entirely  absent.  The  quantity  of  the  se- 
cretion is  generally  scant,  sometimes  rather  free.  It  is  more  commonly  a 
morning  drop  but  may  also  occur  during  the  day.  A  free  discharge  is  the 
exception  rather  than  the  rule,  and  the  pus  which  is  formed  at  the  in- 
flamed and  congested  area  in  connection  with  any  stricture  may  simply 
appear  in  the  urine  in  the  form  of  shreds  and  masses. 

There  may  exist  a  certain  amount  of  uneasiness  and  smarting  during 
urination  in  connection  with  strictures,  but  such  subjective  symptoms 
may  be  entirely  absent. 

Increased  frequency  and  urgency  of  urination  may  be  due  to  posterior 
urethritis  or  urethro-cystitis. 

Strictures  in  any  part  of  the  urethra  may  be  attended  by  pain  felt 
either  at  the  point  where  the  stricture  is  located  or  referred  to  the  meatus 
or  to  some  other  portion  of  the  canal.  Frequency  of  urination  is  much 
more  marked  when  the  deeper  regions  are  involved,  such  urinary  fre- 
quency being  relatively  greater  by  day  than  by  night.  Epididymitis, 


118 


VENEREAL  DISEASES. 


sometimes  acute  and  sometimes  mild  and  relapsing,  occurs  in  connection 
with  strictures,  notably  those  which  are  irritable,  inflamed,  or  of  small 
calibre  and  so  situated  as  to  affect  the  deeper  portion  of  the  urethra  and 
the  vesical  neck.  Retention  of  urine  occurs  with  variable  frequency. 
While  it  is  more  liable  to  complicate  stricture  involving  the  deeper 
regions,  it  may  occur  as  a  result  of  reflex  spasm  in  connection  with  stric- 
ture in  the  anterior  portion.  Some  patients  are  much  more  liable  to  be 
attacked  by  this  symptom  than  others,  especially  those  of  a  neurotic  tem- 
perament, although  anything  which  is  likely  to  cause  hyperaemia  of  the 
mucous  membrane  overlying  the  compressor  urethrse  muscle,  such  as  cold 
or  the  passage  of  instruments,  may  be  the  means  of  provoking  this  com- 
plication. 

The  ultimate  result  of  long-continued  tight  stricture  is  generally 
chronic  inflammation  of  the' bladder  attended  by  thickening  of  the  vesical 
wall,  contraction  of  its  cavity  with  contracture  or  sometimes  dilatation 
and  atony,  resulting  perhaps  in  constant  dribbling  of  urine  due  to  over- 
flow of  the  distended  organ  and  loss  of  power  of  the  vesical  and  mem- 
branous sphincters. 

Finally,  as  the  result  of  tight  stricture  extends  itself  upward,  dilata- 
tion of  the  ureter  and  pelvis  of  the  kidney  and  pyelonephritis  are  brought 
about,  which  may  lead  at  any  time  to  a  fatal  issue  by  an  attack  of  acute 
uraemia,  or  after  a  long  duration  to  a  slowly  progressive  condition  of  kid- 
ney insufficiency. 

DIAGNOSIS. 

The  physical  examination  of  the  urethra  is  conducted  by  means  of 
bougies  of  various  kinds  and  solid  steel  sounds.  These  instruments  are 
graded  as  to  size  in  accordance  with  the  different  scales  of  measurement 
commonly  in  use,  known  as  the  French,  English,  and  American.  The 
relative  sizes  of  these  scales  are  shown  in  the  accompanying  table : 

TABLE  OF  THE  APPROXIMATE  RELATIONS   BETWEEN  THE  ENGLISH,  AMERICAN,  AND 

FRENCH  SCALES. 


English. 

American. 

French. 

English. 

American. 

French. 

1 

3 

5 

12 

14 

21 

2 

4 

6 

13 

15 

23 

3 

5 

7 

14 

16 

24 

4 

6 

9 

15 

17 

26 

5 

7 

10 

16 

18 

27 

6 

8 

12 

17 

19 

29 

8 

9 
10 

14 
15 

18 
19 

20 
•21 

30 
32 

9 
10 
11 

11 
12 
13 

17 
18 
20 

20 
21 

22 

22 
23 
24 

33 

35 
36 

The  metal  steel  sounds  (Figs.  61,  62)  are  blunt  or  conical  at  the  extrem- 


STRICTURE   OF  THE  URETHRA. 


119 


ity.  The  former  are  used  for  diagnostic  purposes,  the  latter  for  dilata- 
tion. The  reason  for  this  is  obvious. 
The  shoulder  of  a  blunt  instrument  can 
more  readily  detect  the  presence  and 
the  nature  of  the  urethral  obstruction, 
while  the  tapered  sound  can  be  more 
readily  engaged  in  a  narrowing  of  the 
canal  and  is  better  for  dilating  purposes. 
We  are  accustomed  to  employ  in  dilating 
the  urethra  a  sound  which  is  tapered  in 
both  directions,  toward  the  handle  as 
well  as  toward  the  extremity,  the  object 
of  which  is  to  avoid  the  continued  disten- 
tion  of  the  meatus,  especially  when  this 
part  is  constricted,  while  the  deeper  por- 
tion of  the  canal  is  being  subjected  to  the 
required  amount  of  distention  (Tig.  67, 
p.  126). 

Acorn-shaped  bulbous  bougies,  the 
bougie  a  boule  (Fig.  63),  which  are  con- 
structed of  metal  or  flexible  rubber,  are 
preferable  to  the  sound  for  exploring  the 
anterior  urethra.  They  readily  detect  the 
presence  of  strictured  areas  in  entering 
the  canal  and  upon  withdrawal  will  carry 
upon  the  shoulder  a  drop  of  pus  or  blood 
as  evidence  of  the  inflamed  area  behind 
the  strictured  portion. 

Flexible  gum  elastic  olivary  bougies 
(Fig.  64)  may  be  used  both  for  diagnostic 
purposes  and  also  for  dilatation. 

Filiform  whalebone  bougies  (Fig.  65) 
are  very  delicate  whiplike  instruments  with  straight  and  corkscrew  ends 


FIG.  61.  —  Blunt 
Steel  Sound. 


FIG.  62.  —  Conical 
Steel  Sound. 


FIG.  63.— Flexible  Bulbous  Bougie. 


120 


VENEREAL  DISEASES. 


used  for  the  purpose  of  finding  the  orifice  of  strictures  of  very  small 
calibre  which  are  impermeable  to  any  of  the  larger-sized  exploring  in- 
struments, and  having  passed  through  the  stricture  into  the  bladder  are 
employed  as  a  guide  upon  which  the  tunnelled  sound  or  catheter  is  passed 
either  for  the  purpose  of  dilatation  or  to  serve  as  a  guide 
in  incising  the  urethra  through  the  perineum.  Sometimes 
a  number  of  these  small  filiform  bougies  are  packed  to- 
gether in  the  urethra  and  then  alternately  manipulated 
until  one  shall  have  engaged  and  passed  the  obstacle  (Fig. 
69,  p.  131). 

By  means  of  the  endoscope  or  urethroscope  the  urethra 
may  be  inspected  and  the  character  and  extent  of  a  strict- 
ured  area  observed.  While  such  means  are  useful  and  in- 
structive for  the  purposes  of  study  and  scientific  obser- 
vation, from  a  practical  standpoint  the  ordinary  urethral 
exploring  instruments  are  more  useful  for  diagnostic  pur- 
poses. 

When  a  stricture  of  large  calibre  is  important  enough 
to  yield  any  symptom  besides  the  possible  spasmodic 
and  reflex  irritative  phenomena  referred  to  and  the 
gleety  discharge,  there  are  certain  physical  means  of 
diagnosis  which  yield  satisfactory  results. 

The  physical  diagnosis  of  stricture  of  large  cali- 
bre is  generally  easy.  A  bulbous  bougie  (Fig. 
63),  metal  or  gum  elastic,  as  large  as  the  meatus 
will  take,  may  be  warmed,  lubricated,  and  gently 
passed  through  the  urethra.  When  it  comes  to  a 
tight  spot  the  surgeon  can  feel  it  as  well  as  the  pa- 
tient, and  when  it  is  withdrawn  the  resistance  is 
marked  and  the  fibrous  character  of  the  tissue  ap- 
preciated. If  this  spot  be  the  seat  of  the  gleety 
discharge,  the  bulb  of  the  instrument  is  very  often 
faintly  tinged  with  blood  at  its  tip  upon  with- 
drawal. Points  of  stricture  are  often  sensitive; 
their  length  may  be  measured  by  the  aid  of  this 
bulbous  instrument  and  their  number  ascertained  if 
more  than  one  exist.  This  exploration  refers  only 
to  the  pendulous  urethra. 

It  is  important  to  make  a  separate  exploration 
of  the  anterior  and  posterior  sections  of  the  canal, 
and  reach  a  conclusion  as  clear  as  possible  regard- 
ing the  front  urethra  before  invading  the  posterior  portion  of  the  canal. 

If,  on  attempting  this  exploration,  congenital  or  pathological  narrow- 
ing of  the  orifice  of  the  urethra  be  found  to  exist,  the  canal  may  still  be 


/ 

* 


FIG.  64.—  FIG.  65. 

Flexible  —Filiform 

Olivary  Bougies. 
Bougie. 


STRICTURE   OF  THE  URETHRA.  121 

explored  without  cutting  the  meatus  by  the  use  of  the  expanding  ure- 
thrarneter  (Fig.  66)  devised  by  Dr.  Otis.  This  instrument  is  intro- 
duced closed,  capped  with  a  piece  of  thin  rubber,  down  to  the  sinus  of  the 
bulb.  It  is  there  to  be  expanded  until  the  patient  feels  a  slight  disten- 
tion,  and  then  to  be  slowly  withdrawn  toward  the  meatus.  Upon  en- 


C.TIEMANN  &  CO. 


countering  resistance  the  handle  is  turned  so  as  to  make  the  size  of  the 
bulb  smaller,  all  changes  in  the  bulb  being  marked  upon  an  index-plate 
at  the  handle.  The  shaft  of  the  instrument  is  marked  in  inches,  and  by 
its  aid  all  constrictions  in  the  canal  may  be  located,  measured,  and  cali- 
brated. 

In  short,  exploration  by  this  instrument  leaves  nothing  to  desire,  ex- 
cepting a  point  of  departure.  Here,  unfortunately,  it  fails,  for  it  has  to 
assume  either  that  the  size  of  some  portion  of  the  canal  is  the  natural 
size  of  the  whole  course  of  the  urethra  (which  is  manifestly  inaccurate, 
as  as  been  shown),  or  the  surgeon  has  to  assume  some  arbitrary  dimension 
as  being  the  proper  size  of  the  urethral  canal. 

Moreover,  with  this  instrument,  damage  is  apt  to  be  inflicted  upon  a 
sensitive  urethra,  which  may  and  often  does  lead  to  an  aggravation  of  all 
the  symptoms  for  which  the  exploration  was  made,  and  to  the  lighting  up 
of  new  ones.  This  instrument  does  excellent  service  at  times,  mainly  in 
the  way  of  accurately  locating  strictures  in  the  pendulous  urethra,  which 
the  surgeon  has  decided  should  be  cut. 

When,  therefore,  the  meatus  is  small  and  the  urethra  has  to  be  ex- 
plored, the  stricture  of  the  meatus,  and  any  tight  spot  within  the  first 
three-quarters  of  an  inch  from  the  meatus,  may  be  cut  at  once  as  a  part 
of  the  examination.  If  the  meatus  alone  is  involved,  it  may  be  cut  down 
to  the  bottom  of  any  pouch  lying  behind  either  of  its  angles,  and 
fully  two  sizes  (American  scale)  larger,  for  in  healing  it  will  contract 
somewhat,  and  it  should  be  left  so  that  when  well  it  may  be  at  least 
physiologically  large.  Any  band  smaller  than  the  new  cut  meatus 
and  lying  near  it  should  also  be  cut  at  the  same  sitting,  as  part  of  the 
examination. 

This  course  is  advised  for  several  reasons.  First,  the  urethra  cannot 
be  properly  explored  from  before  backward  with  a  bulbous  bougie,  unless 
the  orifice  of  the  urethra  will  admit  the  passage  of  a  fair-sized  bulb  and 
no  organic  stricture  deeper  seated  can  be  treated  with  sufficiently  large 
instruments  unless  the  meatus  is  prepared  for  their  reception. 


122  VENEREAL  DISEASES. 

The  operation  itself  is  trivial  in  importance,  and  never,  when  per- 
formed upon  a  urethra  which  would  tolerate  any  interference  whatever  or 
was  tit  for  any  examination,  has  given  rise  to  any  complication  or  subse- 
quent discomfort.  The  use  of  the  sound  upon  the  deep  urethra  after 
cutting  the  meatus  is  inadvisable,  and  may  lead  to  disagreeable  compli- 
cations— cystitis,  posterior  urethritis,  urethra!  chill. 

The  meatus  then  should  be  cut  a  little  larger  than  full  size,  and  the 
bulb,  then  introduced  as  through  a  natural  meatus,  will  detect  strictures 
in  the  pendulous  urethra,  if  there  be  any. 

Stricture  of  large  calibre  of  the  bulbo-membranous  junction  may  be 
sought  for  with  a  blunt  (not  a  conical),  well-warmed  steel  sound,  of  a 
size  as  large  as  the  anterior  urethra  will  admit;  and  it  is  sometimes  diffi- 
cult to  distinguish  between  true  stricture  and  spasm.  If  there  be  spas- 
modic stricture,  such  an  instrument  will  generally  go  in  if  properly 
handled. 

The  blunt  sound,  well  warmed  and  lubricated,  should  be  gently  car- 
ried down  the  urethra  and  its  beak  presented  accurately  at  the  hole  in 
the  triangular  ligament.  Here  it  should  be  held  under  even  pressure — 
rather  firm,  but  not  violent — a  perfectly  uniform  pressure  and  with  a  very 
steady  hand,  for  several  minutes  if  need  be.  The  patient  meantime 
should  be  entertained  and  diverted,  the  scrotum  being  held  well  up  by 
the  unemployed  hand,  which  at  the  same  time  steadies  the  beak  and  the 
curve  of  the  instrument  through  the  perineum.  If  under  such  a  man- 
oeuvre the  sound  does  not  presently  slip  along  and  glide  smoothly  and 
rather  swiftly  into  the  bladder,  especially  if  under  cocaine  or  general  an- 
aesthesia, it  may  be  either  because  the  stricture  is  not  spasmodic,  or  be- 
cause the  beak  of  the  instrument  has  not  been  properly  brought  to  bear 
upon  the  cramped  muscles. 

The  diagnosis  of  stricture  of  small  calibre  is  more  easily  made  than 
that  of  stricture  of  large  calibre. 

Congenital  constriction  of  the  meatus,  external  or  internal,  may  be 
readily  seen  or  detected  by  instruments.  The  existence  of  a  tight  area 
along  the  pendulous  urethra  is  discovered  without  difficulty.  Sometimes 
it  may  be  felt  upon  the  exploring  instrument,  and  often  when  composed 
of  modular  tissue  it  may  be  felt  from  the  outside.  It  is  well  to  begin 
with  an  instrument  of  medium  size  and  carefully  note  the  depth  at  which 
its  further  entrance  is  obstructed,  and  then  by  carefully  going  down  the 
scale  the  correct  size  of  the  calibre  of  the  stricture  may  be  determined. 
In  the  same  manner  when  several  contracted  areas  exist  they  can  be 
detected,  located,  and  measured. 

In  exploring  the  deeper  portion  of  the  canal  a  blunt,  curved  steel 
instrument  should  be  employed,  and  the  size  gradually  diminished  until 
one  which  will  pass  the  constricted  area  is  found.  Very  small  steel  in- 
struments, unless  deftly  handled,  are  dangerous  and  may  cause  false 


STRICTURE   OF  THE  URETHRA.  123 

passages  in  the  canal ;  and  therefore  if  the  apparent  size  of  the  strictnre 
calls  for  the  use  of  a  very  small  instrument,  it  is  better  to  employ  gum 
elastic  olivary  bougies,  which  will  serve  the  same  purpose  and  are  less 
dangerous. 

When  the  point  of  narrowing  is  contracted  sufficiently  to  oppose 
the  entrance  of  even  the  olivary  instruments,  after  the  question  of 
spasm  has  been  considered  and  eliminated,  it  may  be  necessary  to  resort 
to  the  filiform  bougie;  and  having  engaged  one  of  these  small  instru- 
ments in  the  mouth  of  the  stricture,  it  is  sometimes  possible  to  gain  an 
entrance  with  a  bougie  several  sizes  larger.  Nothing  need  be  added  to 
what  has  already  been  said  concerning  the  possibility  of  confounding 
spasm  of  the  deep  urethra  with  true  organic  stricture.  If  the  precaution 
be  taken  to  commence  the  urethral  examination  with  a  large-sized  blunt 
steel  instrument,  thoroughly  warmed,  and  to  proceed  as  directed,  error  is 
hardly  possible.  In  a  doubtful  case,  if  the  meatus  is  very  small  it  may 
not  be  possible  to  use  a  large  enough  blunt  steel  instrument  to  decide  the 
question  of  spasm.  A  surgeon  may  sometimes  declare  that  no  instru- 
ment will  pass  because  he  has  used  a  fine  whalebone  to  commence  with, 
and  having  caught  this  instrument  in  some  follicle,  has  been  unable  to 
reach  the  bladder ;  or  he  may  have  passed  the  instrument  into  the  blad- 
der, and  finding  it  is  held  somewhat  by  spasmodic  contraction  on  its  way 
out,  has  decided  that  there  is  tight  organic  stricture  equivalent  to  the 
size  of  the  instrument.  Finally,  if  no  instrument  can  be  passed  and  the 
question  between  spasm  and  true  stricture  remains  undecided,  a  general 
anaesthetic  may  be  administered,  when  a  filiform  bougie  in  the  case  of 
tight  stricture  or  a  large  instrument  when  urethral  spasm  exists  may 
be  introduced  after  all  attempts  without  the  anaesthetic  have  failed ;  and 
thus  a  stricture,  if  present,  may  be  located,  its  permeability  ascertained, 
and  its  calibre  estimated. 

TREATMENT. 

There  is  no  one  method  which  can  be  applied  to  the  treatment  of  all 
strictures. 

The  general  treatment  consists  in  the  employment  of  such  remedies  as 
are  known  to  have  special  value  in  inflammatory  conditions  of  the  genito- 
urinary tract,  while  those  things  which  are  known  to  be  a  sourse  of  irri- 
tation to  this  region  should  be  discreetly  avoided. 

The  surgical  treatment  of  stricture  is  of  great  importance.  Various 
surgical  measures  have  been  employed,  the  principal  and  most  important 
of  which  are  dilatation,  progressive  or  rapid,  urethrotomy,  internal  and 
external,  divulsion  and  electrolysis. 

It  cannot  be  reasonably  stated  that  all  strictures  should  be  treated  by 
any  one  of  the  various  methods  in  vogue.  Electrolysis  has  been  weighed 


124  VENEREAL  DISEASES. 

by  experience  and  found  wanting.  We  have  tested  it  thoroughly  and  re- 
ject it  absolutely. 

It  is  extravagant  to  state  that  all  strictures  should  be  cut — a  doctrine 
which,  although  never  universally  accepted,  has  been  too  widely  applied 
of  late  years  by  those  who  looked  upon  the  urethra  as  a  canal  with  a  uni- 
form calibre  throughout,  and  regarded  it  as  necessary  to  remove  by  in- 
cision any  encroachment  upon  this  calibre.  It  is  equally  unjust,  on  the 
other  hand,  to  say  that  all  strictures  should  be  dilated,  for  there  are  de- 
cided exceptions  to  such  a  rule,  and  it  is  as  impossible  to  generalize  with 
respect  to  this  method  of  treatment  as  it  is  in  regard  to  the  others.  Some 
strictures  are  more  satisfactorily  treated  by  cutting;  many  others,  and 
probably  the  majority,  are  well  adapted  to  the  treatment  by  dilatation,  and 
should  be  treated  by  this  method. 

The  choice  between  dilatation  and  cutting  should  generally  be  made 
in  favor  of  the  former,  but  the  size  of  the  stricture  is  not  necessarily  a 
guide  to  the  choice  of  treatment.  Some  very  tight  strictures  can  be 
easily  dilated  and  are  therefore  appropriate  for  this  method,  whereas 
some  very  large  strictures,  while  the  dilating  instrument  can  be  readily 
passed,  yet,  on  account  of  the  elasticity  and  resiliency  of  the  tissues,  will 
recontract  so  rapidly  that  anything  approaching  a  cure  is  impossible  un- 
less cutting  be  resorted  to. 

To  summarize  the  various  methods  of  treatment  as  applied  to  the  dif- 
ferent forms  of  stricture,  we  might  lay  down  the  following  rules : 

1.  All  soft  strictures,  whether  of  the  anterior  or  posterior  urethra, 
should  be  treated  by  dilatation. 

2.  Strictures  of  a  fibrous  character,  whether  of  small  or  large  calibre, 
should  be  treated  by  dilatation  at  first,  and  when  dilatation  fails  or  the 
stricture  is  intractable  beyond  a  certain  point  by  this  method,  urethrotomy 
should  be  resorted  to. 

3.  Strictures  of  large  or  small  calibre  which  are  readily  dilatable, 
but  which  recontract  after  a  very  short  interval  so  as  to  render  it  neces- 
sary to  continue  the  use  of  the  dilating  instrument  at  frequent  and  short 
intervals,  should  be  cut  for  the  purpose  of  making  such  intervals  of  longer 
duration. 

4.  Strictures  of  the  anterior  urethra  which  require  cutting  should  be 
treated  by  internal  urethrotomy. 

5.  Strictures  which  occur  at  the  bulbo-membranous  junction  or  be- 
hind it,  and  require  cutting,  should  be  treated  by  external  urethrotomy. 

6.  Strictures  of  small  calibre  which  on  account  of  their  depth  and 
proximity  to  the  posterior  urethra  are  accompanied  by  severe  posterior 
urethritis  and  cystitis  are  sometimes  more  suitably  treated  by  external 
urethrotomy  on  account  of  the  additional  benefits  derived  through  the 

efficient  drainage  of  the  bladder   and  posterior  urethra,   which   is  ob- 
tained by  means  of  this  operation. 


STRICTURE   OF  THE    URETHRA.  125 

7.  Strictures  of  the  bulbous  and  bulbo-membranous  urethra  which 
are  constructed  of  fibrous  inodular  tissue  should  be  treated  by  external 
urethrotomy  and  the  mass  of  inodular  tissue  excised. 

8.  Irritable  strictures,  and  those  occurring  in  individuals  particularly 
prone  to  urethral  chills  after  the  employment  of  instruments  in  spite  of 
proper  antiseptic  precautions,  may  be  properly  treated  by  external  or 
internal   urethrotomy,   according   to   the   depth    of    the    stricture,    and 
sometimes  with  more  satisfactory  results  than  by  dilatation. 

Electrolysis. — Electrolysis  is  mentioned  only  to  be  condemned.  Its 
claims  have  not  been  established.  It  is  just  now,  however,  one  of  the 
methods  in  use,  and  therefore  should  be  described. 

Generally  speaking,  the  electrolytic  treatment  of  strictures  is  employed 
by  two  methods — one  in  which  the  strength  of  the  current  applied  is  of 
great,  and  the  other  in  which  it  is  of  feeble  intensity.  The  principle  upon 
which  rests  the  alleged  value  of  the  galvano-caustic  chemical  action  lies 
in  the  fact  that  a  cicatrix  remaining  after  the  application  of  a  caustic 
alkali  is  soft  and  not  retractile  in  character;  that  when  a  galvano-cautery 
is  applied  to  living  animal  tissue  it  is  found  that  at  the  positive  pole  there 
exists  such  a  cicatrix  as  is  produced  by  the  application  of  an  acid,  while 
at  the  negative  pole  is  found  one  similar  to  that  produced  by  the  action 
of  caustic  alkalies.  The  method  of  electrolysis,  as  recommended  by  Fort, 
is  an  example  of  the  employment  of  the  galvano-caustic  current  of  strong 
intensity,  and  his  instrument  resembles  somewhat  the  Maisonneuve  ure- 
throtome.  The  other  method  of  electrolysis,  which  consists  in  the  appli- 
cation of  a  current  of  feeble  intensity  to  the  strictured  area,  constitutes 
what  is  known  as  the  Newman  method.  The  instrument  employed  is  a 
metal  olive  bougie,  of  a  size  as  large  as  can  be  introduced  in  the  urethra 
and  engaged  in  the  stricture.  The  galvanic  current,  which  does  not  ex- 
ceed three  to  five  milliamperes,  is  applied  for  about  ten  minutes,  at  the 
end  of  which  time  the  bulbous  instrument  is  supposed  to  pass  with  greater 
facility  through  the  strictured  area. 

It  will  be  seen  from  a  description  of  the  instruments  employed  in  these 
two  methods  that  one  is  shaped  like  a  cutting  and  the  other  like  a  dilat- 
ing instrument;  that  one  is  rapid  and  employs  a  current  sufficient  to  en- 
able the  blade  to  penetrate  the  tissues ;  that  the  other  is  mild  and  gradual 
and  rather  aims  at  distending  the  constriction.  It  is  therefore  more  than 
doubtful  whether  the  addition  of  the  electric  current  accomplishes  any 
more  in  these  two  operative  procedures  than  what  is  attained  by  instru- 
ments so  closely  resembling  them,  minus  the  addition  of  electricity,  and, 
in  fact,  there  is  a  well-founded*  belief  that  the  electro-chemic  action  pro- 
duces a  detrimental  effect  upon  the  tissues. 

Progressive  Dilatation. — Steel  instruments,  nickelled,  conical  in  shape, 
are  most  serviceable,  and  do  the  most  accurate  as  well  as  the  most  effec- 
tive work  in  dilating  the  canal,  either  pendulous  or  deep,  provided 


126 


VENEREAL  DISEASES. 


the  size  of  the  instrument  is  as  large  as  No.  10  American  (15 
French).  Should  the  stricture  be  smaller  than  this  size,  soft  instru- 
ments are  best  to  commence  with. 

The  conical  instrument  (Fig.  67)  tapers  for 
two  and  three-quarter  inches,  and  should  be 
made  upon  what  is  called  the  short  curve,  with 
an  extra  shortness  of  the  curve  at  the  last  half- 
inch  near  the  beak,  since  this  extra  curve 
greatly  facilitates  introduction,  especially  at  the 
hole  in  the  triangular  ligament,  by  keeping  the 
point  of  the  instrument  against  the  roof  of  the 
canal.  It  should  also  taper  in  the  direction  of 
the  handle  after  maintaining  its  full  size  for 
about  two  inches.  With  this  instrument  the 
meatus,  which  is  often  somewhat  contracted,  is 
x  not  kept  upon  the  stretch  while  the  deeper  por- 

£  tion  of  the  canal  is  being  distended.     Such  an 

£ 

®   instrument,  as  large  as  the  stricture  will  admit, 

§  lubricated  and  warmed,  should  be  passed  with 

«  great  gentleness  well  into   the  bladder.     The 

|  power  of  the  instrument  is  great,  being,  as  it  is, 

|  a  compound  of  wedge  and  lever,  and  the  surgeon 

~   should  exercise  sufficient  control  so  as  not  to  do 

8 

|   damage   to  the  urethra.     The  passage  of   one 

I    such   instrument  as  this  is  equivalent  to   the 
^   passage  of  from  seven  to  nine   sounds  of  the 
E   blunt  pattern,  since  the  conicity  extends  through 
as  many  sizes. 

The  instrument  is  to  be  introduced,  and 
then,  very  gently,  immediately  withdrawn.  If 
the  urethra  be  irritable  at  the  first  sitting,  only 
one  sound  should  be  passed — a  sound  of  mod- 
erate size. 

The  time  most  appropriate  for  a  reintro- 
duction  of  the  steel  sound  in  case  of  stricture 

^K  ,'^^g 

H  JF.m  °*    large   calibre   must  be   determined   by  the 

effect   produced  by   the    instrument    upon    its 
trial  trip.     The  immediate  effect  is  often  only 
an  increase  in  the  amount  of  pain  experienced 
during  urination. 

After  a  day  or  two  the  discharge  from  the  urethra  often  visibly  in- 
creases ;  but  this  subsides  spontaneously  or  by  the  aid  of  a  very  mild  in- 
jection, and  at  the  end  of  four  or  five  days  the  symptoms  for  which  the 
sound  was  introduced  have  reached  the  same  grade  as  that  at  which  they 


STRICTURE   OF   THE   URETHRA.  127 

existed  at  the  moment  of  the  first  introduction  of  the  sound.  Forty-eight 
hours  should  be  allowed  to  pass,  or  even  longer,  after  the  first  instrument, 
and  then  a  sound  of  one  or  two  sizes  larger  may  be  introduced,  but  it  is 
well  to  precede  this  by  a  smaller  instrument. 

The  result  of  this  second  instrumentation  is  that  the  symptoms  are 
less  aggravated  by  it  than  they  were  by  the  first,  improvement  arrives  a 
little  sooner,  is  more  marked,  and  remains  longer.  In  this  way,  increas- 
ing the  sizes  and  using  on  each  occasion  a  conical  sound  as  large  as  will 
pass,  the  symptoms  of  the  stricture  generally  yield  entirely.  The  most 
effective  treatment  by  large  instrument  is  that  which  leaves  an  interval  of 
one  week  between  the  passages  of  the  sound. 

After  the  symptoms  have  disappeared  the  treatment  should  be  discon- 
tinued gradually.  In  some  mild  cases  of  stricture,  not  resilient  and  not 
traumatic,  treatment  may  be  suspended  entirely  after  a  few  weeks,  and 
the  patient  is  and  remains  well  for  an  indefinite  period,  excepting  that  he 
is  capable  of  getting  a  urethritis  from  a  lighter  cause  than  if  he  had  never 
had  previous  trouble.  If  he  does  not  expose  himself,  however,  to  the 
causes  of  urethritis,  he  may  marry  and  remain  well  without  ever  showing 
any  symptoms  of  lack  of  health  in  his  urinary  or  genital  apparatus ;  but 
often  at  the  end  of  a  certain  period,  whether  a  new  provoking  cause  be 
added  or  not,  symptoms  of  irritation  arise,  indicating  recontraction  of 
the  strictured  area,  when  the  passage  of  sounds  is  again  called  for,  the 
single  introduction  of  which  may  be  sufficient  to  carry  him  over  another 
period  of  similar  or  longer  duration  before  the  evidence  of  recontraction, 
again  recurs.  By  stringing  out  and  extending  the  intervals  in  this  man- 
ner it  is  often  possible  practically  to  discontinue  the  use  of  the  sound. 
This  is  especially  true  concerning  strictures  of  large  calibre  of  the  pendu- 
lous urethra,  those  for  which  such  splendid  results  in  the  way  of  radical 
cure  are  claimed  by  the  advocates  of  the  perpetual  use  of  the  knife. 
Truly,  in  those  cases  cured  by  dilatation,  the  urethrameter,  if  screwed  up 
to  make  the  bulb  large  enough,  will  detect  tight  places  along  the  pendu- 
lous urethra  after  cure;  but  so  it  would  have  done  when  the  patient  was 
virgin  of  all  disease,  and  it  has  already  been  shown  that  tight  places  in 
the  pendulous  urethra,  without  symptoms,  need  not  be  strictures  at  all. 

There  is  a  class  of  strictures  which  produce  varied  symptoms — 
generally  of  mild  urethritis — which  do  not  yield  entirely  to  dilatation, 
nor  do  their  symptoms  disappear  under  the  use  of  the  steel  sound. 
They  are  resilient,  that  is,  they  have  in  them  that  tenacious,  elastic,  re- 
tractile quality  which  does  not  allow  dilatation  to  affect  them  favorably 
beyond  a  certain  point.  The  symptoms  yield,  but  do  not  entirely  disap- 
pear. A  little  discharge  in  the  morning  continues  to  mock  the  efforts  of 
the  surgeon  and  to  disgust  the  patient  with  his  disease.  In  these  cases, 
after  being  certain  to  locate  the  symptoms  accurately  in  the  stricture,  and 
not  to  be  deceived  by  ascribing  gleet  due  to  diathetic  or  other  cause  to  a 


128  VENEREAL   DISEASES. 

tight  spot  found  in  the  urethra,  the,advisability  arises  of  internal  urethro- 
tomy  within  the  pendulous  urethra  if  the  stricture  be  located  in  that  re- 
gion. Under  these  circumstances,  the  operation  offers  a  good  chance  of 
success  in  ridding  the  patient  both  of  the  final  remains  of  his  symptoms 
and  of  the  necessity  for  a  continuation  in  the  use  of  sounds — if  the  surgeon 
cuts  wide  enough  at  any  one  point  and  passes  entirely  through  the  un- 
yielding contractile  ring  of  stricture. 

The  treatment  by  internal  urethrotomy,  however,  is  generally  applic- 
able only  to  the  pendulous  urethra.  All  organic  strictures  at  or  deeper 
than  the  bulbo-membranous  junction  should,  if  possible,  be  treated  by  dila- 
tation alone — by  dilatation  to  the  greatest  limit  to  which  it  can  be  carried 
with  gentleness — and  this  will  cure  the  symptoms,  or  so  nearly  cure  them 
that  most  sensible  men  who  are  made  familiar  with  the  dangers  of  internal 
urethrotomy  in  the  curved  portion  of  the  urethra  will  be  satisfied  with  the 
result. 

Such  a  cure,  or  relative  cure  of  stricture  in  the  deep  urethra,  espe- 
cially in  bad  cases  of  inodular  stricture,  cannot  be  maintained  excepting 
at  the  expense  of  constant  dilatation.  The  patient  is  condemned  to  pass 
an  instrument,  at  such  intervals  as  may  be  found  necessary  (about  once  a 
month,  and  after  a  time  at  longer  intervals),  for  the  remainder  of  his  life 
in  order  to  keep  down  his  symptoms  and  to  prevent  the  recontraction  of 
his  stricture.  And  this  is  still  the  case,  no  matter  by  what  treatment  the 
urethra  has  been  brought  to  such  a  size  as  to  allow  the  passage  of  a  full- 
sized  instrument  into  the  bladder.  Eepeatedly  does  the  surgeon  find,  in 
hospital  and  dispensary  practice,  cases  of  tight  stricture  in  the  curved 
urethra  which  have  already  been  subjected  once,  twice,  or  perhaps  three 
times  to  internal  urethrotomy,  or  even  to  external  urethrotomy.  We  have 
performed  perineal  section  more  than  once  under  each  of  these  circum- 
stances, when  the  patients,  from  neglect  to  pass  the  sound  continuously 
after  a  former  cutting,  had  allowed  the  urethra  to  close  at  the  point  of 
stricture.  And  we  have  treated  a  large  number  by  dilatation  after  recon- 
traction had  followed  the  cutting  operation. 

Stricture  of  large  calibre  in  the  pendulous  urethra  may  be  treated  so 
that  its  sympoms  may  cease  forever,  without  the  necessity  for  any  further 
use  of  instruments  in  the  canal. 

The  same  is  true  regarding  the  treatment  of  stricture  of  the  deep 
urethra. 

Resilient  stricture  of  large  calibre  in  thependiilous  urethra  is  often  in- 
curable except  by  the  knife;  and  internal  urethrotomy,  if  the  cut  be  large 
enough,  will  generally  cure  the  symptoms  of  such  a  stricture  so  that  they 
will  not  return,  although  no  instruments  are  used  in  the  urethra  after  the 
cut  is  well. 

Small  organic  strictures  in  the  pendulous  urethra  are  probably  always 
best  managed  by  internal  urethrotomy. 


STRICTURE   OF   THE   URETHRA.  129 

Strictures  of  the  deep  urethra,  when  organic  and  situated  at  or  beyond 
the  bulbo-niembranous  junction,  cannot,  all  of  them,  with  certainty  be 
radically  cured  by  any  operation  or  by  any  treatment.  The  best  treat- 
ment in  these  cases  is  dilatation  when  practicable.  Sometimes,  after 
dilatation  has  been  maintained  for  a  long  period,  the  tendency  to  recon- 
traction  ceases,  and  the  patient  remains  well,  so  far  as  symptoms  are  con- 
cerned, without  the  necessity  of  any  further  instrumentation  in  the  urethra. 
Possibly  a  like  cure  may  occasionally  follow  internal  urethrotomy;  but, 
in  the  majority  of  instances  of  nodular,  organic,  and  traumatic  strictures 
of  the  deep  urethra  a  cure  is  not  obtained  radically  by  any  operation  yet 
known,  and  the  patient' s  safety  consists  in  a  maintenance  of  the  calibre 
of  his  urethra  by  the  occasional  passage  of  a  full-sized  instrument  through 
the  obstruction  for  the  rest  of  his  life — a  task  not  considered  at  all  diffi- 
cult by  those  who  do  it. 

Strictures  of  small  calibre  in  the  pendulous  urethra,  when  they  are 
fibrous  and  resistant,  should  be  cut,  since  they  are  quite  certain  in  the 
long  run  to  prove  resilient,  and  require  cutting  perhaps  after  much  time 
has  been  lost  in  attempts  at  dilatation.  If  they  prove  too  narrow  to  re- 
ceive the  urethrotome,  their  calibre  may  be  raised  in  a  few  days  by  dila- 
tation, and  then,  as  soon  as  the  urethrotome  will  pass  comfortably,  they 
may  be  cut. 

Tor  all  strictures  of  the  deep  urethra  dilatation  should  be  the  rule 
and  all  operative  measures  the  exception,  for  the  double  reason  already 
stated :  1.  An  operation  may  mean  unnecessary  danger  to  the  patient,  and 
such  a  risk  as  his  physical  condition  may  not  warrant.  2.  After  cutting 
internally  or  externally,  and  after  divulsiou,  a  radical  cure  is  not  attained 
in  most  instances — only  relief  as  a  rule,  which  is  made  effective  by  a  con- 
tinuance of  dilatation,  at  more  or  less  prolonged  intervals,  for  an  indefi- 
nite period. 

Dilatation  of  stricture  of  small  calibre  is  done  much  after  the  man- 
ner advised  in  the  case  of  stricture  of  large  calibre,  with  the  excep- 
tion that,  when  soft  instruments  are  used,  the  intervals  may  be  consider- 
ably shortened.  Practically,  however,  the  rule  is  the  same.  When  the 
effect  of  one  dilatation  is  at  its  height,  another  larger  instrument 
should  be  gently  introduced  and  immediately  withdrawn.  With  very 
fine  instruments,  one  day  is  a  long  enough  interval  to  be  allowed  to 
pass  after  the  first  sitting;  then  the  interval  may  be  raised  to  two, 
then  to  three  and  four  days,  with  advantage.  As  soon  as  size  10  Ameri- 
can is  reached,  soft  instruments  may  be  abandoned  and  the  dilatation 
continued  with  conical  steel  sounds,  as  in  the  case  of  stricture  of  large 
calibre. 

In  attempting  to  dilate  a  stricture  of  very  small  calibre  considerable 
difficulty  may  sometimes  be  encountered.     After  a  small  size  steel  sound 
has  been  tried  in  vain,  an  effort  to  reach  the  bladder  may  be  made  with 
9 


VENEREAL  DISEASES. 

a  small,  soft,  black  conical  bougie,  sharp-pointed,  not  olivary  (Fig.  68). 
Several  small  sizes  of  these  may  be  tried. 

If  any  instrument  so  far  tried  passes  the  stricture,  the  amount  of  ease 
with  which  it  glides  through  the  tight  spot  should  be  estimated,  the  in- 
strument immediately  withdrawn,  and,  unless  there  be  some  special  rea- 
son to  the  contrary,  the  patient  should  be  let  alone  to  see  what  effect  will 
follow  the  first  instrumentation.  If  urethra!  fever  follows,  and  especially 
if  the  patient  has  albumin  in  his  urine,  all  subsequent  explorations  must 
be  made  with  special  care,  and  with  the  proper  antiseptic  precautions  and 
medical  aids  for  the  prevention  of  chill,  which  will  be  mentioned  later. 

If  none  of  the  instruments  thus  far  tried  will  pass,  a  very  valuable  in- 
strument still  remains— the  filiform  whalebone  bougie,  with  the  point 
twisted  into  spiral,  or  bent  so  as  to  be  thrown  out  of  the  axis  of  the  shaft 
of  the  instrument  (Fig.  65,  p.  120). 

A  small  syringeful  of  hot  sterilized  oil  is  first  thrown  into  the  urethra, 
and  then  the  surgeon  feels  the  anterior  face  of  the  stricture  with  the 


B.TJBMANN&CO 
FIG.  68. 

twisted  end  of  one  of  these  fine  whalebones.  By  advancing  the  instru- 
ment during  rotation,  with  the  urethra  made  tense  by  pulling  upon  the 
penis,  the  tip  of  the  filiform  bougie  is  presented  at  different  points  upon 
the  face  of  the  stricture,  and  finally,  in  a  skilled  hand,  is  quite  certain  to 
find  the  orifice  of  the  stricture  and  to  enter  it.  Once  entered,  the  rigidity 
of  the  whalebone  comes  into  play,  and  the  instrument  promptly  passes  on 
and  enters  the  bladder.  It  is  rare  indeed  to  encounter  a  stricture  into 
which  one  of  these  slender  little  instruments  cannot  be  made  to  pass ; 
nearly  all  the  so-called  impermeable  strictures  yield  to  them.  The  main 
difficulty  in  their  employment  is  the  facility  with  which  the  point  becomes 
entrapped  in  the  mouths  of  dilated  follicles,  or  of  a  false  passage,  should 
one  exist.  This  defect  may  in  a  measure  be  overcome  by  the  well-known 
device  of  crowding  the  urethra  full  of  these  fine  threads  of  whalebone, 
and  then  pushing  upon  them  alternately  until  the  one  which  presents  at 
the  mouth  of  the  stricture  passes  on  into  the  bladder  (Fig.  69).  An  at- 
tempt to  widen  the  mouth  of  the  stricture  by  distending  the  urethra  in 
front  with  air  or  hydrostatic  pressure  is  an  expedient  sometimes  tried  in 
order  to  gain  an  opening  wedge,  to  be  the  starting-point  of  further 
dilatation. 

But  when,  in  the  case  of  a  very  tight  stricture,  a  fine  whalebone  has 
been  introduced  only  after  long  patient  trial,  and  especially  if  there  be 
actual  or  impending  retention^  the  surgeon' s  course  should  depend  in  a 
measure  upon  the  character  of  the  stricture,  as  well  as  the  patient. 


STRICTURE   OF   THE   URETHRA. 


131 


If  the  stricture  be  modular,  complicated  with  perineal  fistula;  or  very 
hard  and  of  traumatic  origin;  or  attended  by  perineal  abscess;  or 
(above  all)  by  infiltration  of  urine;  or  if  the  patient  be  hard  to  man- 
age, having  been  partly  cured  before  and  then  allowed  himself  to  re- 
lapse; or  if  he  be  urgently  pressed  for  time,  or  subject  to  repeated  and 
prostrating  attacks  of  urethral  fever  (his  kidneys  being  presumably 
sound) — under  any  of  these  circumstances  perineal  section  upon  a  guide 
is  called  for,  and  should  be  performed  at  once  or  within  twenty-four 


FIG.  60.- Method  of  Finding  the  Opening  of  a  Tight  Stricture  with  Filiform  Bougies. 

hours.  The  filiform  guide  may  be  tied  in  the  urethra  and  left  there 
until  the  operation,  if  there  has  been  great  difficulty  in  procuring  an 
entrance. 

If  the  case  be  not  urgent  on  any  of  the  above  grounds,  while  it  has 
been  quite  difficult  to  pass  the  stricture  with  the  filiform  bougie,  the  mild 
and  very  efficient  expedient  of  continuous  dilatation  may  be  used. 

Continuous  dilatation  is  the  action  exerted  upon  a  stricture  by  the  con- 
stant presence  of  an  instrument  passed  through  it.  The  whalebone  or 
small  gum  elastic  bougie,  once  inserted,  is  simply  to  be  retained  in  place 
by  a  piece  of  heavy  silk  tied  tightly  around  it  near  the  meatus.  The  two 
ends  of  the  silk  are  then  tied  together  so  that  the  knot  shall  lie  upon  the 
frenum  just  at  the  curve  of  the  corona  glandis,  and  then  the  separate  ends 
are  carried  around  on  either  side  under  the  corona,  and  tied  with  moder- 


132 


VENEREAL   DISEASES. 


ate  tightness  upon  the  dorsum.     The  distal  end  of  the  bougie  should 
reach  the  neck  of  the  bladder,  or  rest  just  beyond  it  (Fig.  70). 

In  this  condition  the  patient  is  sent  home  and  told  to  keep  quietly 
about  the  house.  In  twenty-four  hours  the  whalebone  may  be  removed 
and  one  several  sizes  larger  introduced  with  ease.  This  is  in  its  turn 


FIG.  70. 

tied  in.  The  patient  urinates  easily  alongside  of  the  instrument ;  some- 
times there  is  incontinence.  The  continuous  pressure  causes,  first,  mus- 
cular action,  spasm,  and  the  bougie  is  grasped,  then  relaxation  of  spasm, 
then  inflammatory  swelling,  then  absorption,  and  usually  suppuration. 
The  second  instrument  may  be  left  in  two  days  or  more.  In  this  way,  in 


STRICTURE   OF   THE   URETHRA. 


133 


a  week  most  strictures  (if  commenced  with  very  small)  may  be  raised  a 
number  of  sizes.  In  replacing  a  new  bougie,  generally  an  increase  of  two 
or  three  sizes  is  possible,  but  it  should  glide  in  easily  without  pressure. 
It  is  well  during  the  retention  of  the  bougie  to  keep  the  anterior  canal 


FIG.  71.— Kollman  Urethral  Dilators. 

flushed  out  with  an  antiseptic  solution  (boric  acid  three  per  cent,  or  per- 
manganate of  potassium  1  :  4,000).  The  larger  the  calibre  of  the  stric- 
ture, the  less  promptly,  as  a  rule,  does  continuous  dilatation  affect  it. 
After  the  stricture  has  reached  a  reasonable  size,  treatment  by  ordinary 
dilatation  may  be  commenced;  but  the  intervals  must  be  rather  short  at 


134  VENEREAL  DISEASES. 

first,  since  a  stricture  promptly  raised  to  a  large  size  by  this  method  very 
promptly  falls  back  again  if  let  alone. 

There  are  some  cases  of  tight  stricture  in  which  one  may  be  content 
with  simply  passing  a  filiform  instrument  and  not  tying  it  in,  trusting 
that  on  the  following  day  a  larger  size  may  enter,  as  in  ordinary  treat- 
ment by  dilatation. 

Finally,  there  are  cases  not  quite  desperate  enough  to  justify  external 
urethrotomy,  not  able  to  give  the  time  to  ordinary  dilatation  (although  it 
does  not  call  for  a  day  in  the  house,  much  less  in  bed),  and  yet  urgent 
enough  to  justify  prompt  measures  which  shall  afford  speedy  relief.  For 
this  class  of  cases  two  operations  remain — internal  urethrotomy  or  divul- 
sion  (see  p.  142) . 

Rapid  Dilatation. — This  method  differs  from  the  previous  ones  in  that 
it  aims  at  re-establishing  the  normal  calibre  of  the  canal  at  one  sitting. 
In  other  words,  instead  of  being  progressive,  gradual,  and  slow,  it  uses 
force.  A  number  of  instruments  fashioned  on  the  same  principle  have 
been  invented  for  the  application  of  this  method,  notably  by  Tuttle,  Ober- 
lander,  and  Kollrnan  (Fig.  71).  These  instruments  are  capable  of  ex- 
erting a  great  deal  of  force,  and  permit  the  distention  of  the  canal  very 
much  beyond  its  normal  calibre,  as  high  as  45  on  the  French  scale.  This 
method,  which  is  somewhat  rough  and  exercises  its  extreme  distention  on 
a  large  portion  of  the  urethra  not  included  in  the  stricture,  is  something 
of  a  compromise  measure  between  the  mild  and  slower  means  of  progres- 
sive dilatation  and  the  rapid  immediate  means  of  "  divulsion  "  (to  be  re- 
ferred to  later),  and  has  nothing  in  its  favor  to  place  it  before  either  of 
these  two  procedures  in  the  choice  of  treatment. 

Internal  Urethrotomy. — Stricture  far  forward  in  the  urethra  or  con- 
tracted meatus  should  be  cut.  This  is  most  conveniently  done  with  a 
straight,  blunt  bistoury.  The  prepuce  should  be  retracted,  the  head  of 
the  penis  seized  between  the  thumb  and  index  finger  of  the  left  hand,  and 
the  blade  of  the  knife  introduced  to  the  proper  depth  in  the  urethra.  It 
is  generally  best — often  necessary  on  account  of  the  pocket— to  cut  the 
meatus  along  the  floor  of  the  urethra;  but  in  some  peculiar  shapes  of  the 
glans  penis  it  may  be  better  to  cut  the  roof  of  the  urethra.  This  opera- 
tion may  be  rendered  absolutely  painless  by  the  employment  of  cocaine  or 
eucaine. 

A  convenient  method  of  procedure  is  to  have  on  hand  a  half -grain  tablet 
triturate  of  either  of  these  drugs,  which  is  to  be  placed  just  inside  the 
meatus ;  it  becomes  softened  by  the  normal  moisture  of  the  canal,  and  is 
left  in  contact  long  enough  for  absorption  to  occur. 

When  all  is  ready  the  surgeon  squeezes  the  glans  penis  with  the 
thumb  and  finger  which  hold  it,  and  at  the  same  moment  slowly  and 
steadily  draws  the  sharp  blade  along  the  floor  of  the  urethra,  appreciating 
with  his  surgical  sense  of  touch  the  resistance  offered  to  the  knife  by  the 


STRICTURE   OF  THE   URETHRA. 


135 


encircling  band  of  stricture.  When  this  yields  and  is  thoroughly  cut 
through,  he  can  appreciate  it  at  once  by  a  cessation  of  the  feeling  of  re- 
sistance which  the  band  has  given,  and  he  has  cut  enough.  If  it  is  only 
a  pouched  meatus  which  the  surgeon  has  to  transform  into  a  slit,  he  regu- 
lates his  incision  accordingly.  Civiale's  or  any 
other  rneatotome  may  be  used,  if  the  surgeon  pre- 
fers. The  operator  may  place  the  index  finger  of 
his  left  hand  along  the  integument  beneath  the 
urethra,  so  that  the  stricture  band  may  be  felt  be- 
tween the  finger  and  the  knife.  In  this  position  he 
cuts  directly  upon  the  finger  until  he  can  feel  the 
point  of  the  knife  against  the  soft  tissues  and  ap- 
preciate the  absence  of  the  band  between  the  finger 
and  the  knife.  The  baud  of  constriction  behind  a 
tight  meatus  is  readily  detected  with  a  bulbous  in- 
strument; hence  the  bulbous  urethrotome  (Fig.  72), 
a  modification  of  Civiale's,  is  useful  in  incising  it 
at  the  point  of  resistance.  The  meatus  is  often  cut 
improperly.  The  fault  lies  in  either  cutting  too 
much  or  too  little.  Many  cases  are  seen  in  which 
an  unsightly  and  unnecessary  deformity  is  produced 
by  the  operation  of  meatotomy,  amounting  in  some 
instances  almost  to  a  balanic  hypospadias,  the  re- 
sult of  which  is  to  scatter  the  urinary  stream  as  it 
passes  the  meatus,  thereby  causing  much  annoyance. 
On  the  other  hand,  the  meatus  is  insufficiently  cut 
when  the  external  fissure  only  is  enlarged.  Such  a 
case  has  the  outward  appearance  of  an  ample -sized 
meatus,  but  by  an  attempt  to  introduce  a  bulbous 
bougie  it  is  discovered  to  be  surprisingly  small.  The 
interior  constricting  band  has  been  left  untouched, 
and  should  be  cut  with  a  bistoury  or  bulbous  ure- 
throtome, always  upon  the  floor. 

The   cut   meatus    sometimes   bleeds    profusely, 
sometimes  hardly  at  all.    The  expedients  for  stop- 
ping the  blood  consist  in  applying  pressure  for  a 
time,  by  the  application  of  a  strip  of  rubber  plaster 
around  the  extremity  of  the  penis,  or  by  a  snugly  ap- 
plied  narrow  finger  bandage,  with  or   without  the  uretiirotome;  a  modiflca- 
addition  of  a  small  flat  splint.    In  cases  of  moderate  tion  of  Clviale's 
bleeding  the  application -of  several  coats  of  collodion  to  the  well-dried 
meatus,  while  it  is  held  under  pressure  to  prevent  the  oozing  until  the 
collodion  has  set,  may  answer  the  purpose.     There  is  no  danger  from  ex- 
cess of  bleeding,  for  the  patient  can  stop  the  hemorrhage  until  the  surgeon 


D 


FIG.    72.  —  Chetwood's 


}36  VENEREAL,  DISEASES. 

arrives  by  digital  compression,  and  the  surgeon  can  always  finally  arrest 
it  by  properly  applied  pressure,  as  described  above. 

It  is  better  not  to  put  subsulphate  of  iron  into  the  urethra,  since  this 
substance  is  likely  to  leave  the  walls  of  the  canal  inflamed,  hardened, 
and  ready  to  suppurate.  Much  time  in  the  treatment  may  be  lost  on  ac- 
count of  the  use  of  this  haemostatic. 

When  there  is  little  or  no  bleeding,  some  cotton  or  lint,  so  arranged 
as  to  be  retained  beneath  the  prepuce,  is  all  that  is  required.  Often 
when  cocaine  is  used  no  bleeding  occurs  at  the  time,  on  account  of  its  con- 
tracting effect  upon  the  small  vessels;  and  soon  after  this  effect  has  worn 
off  the  bleeding  becomes  quite  free. 

It  is  always  wise  to  caution  the  patient  to  apply  a  snug  bandage  be- 
fore retiring  for  the  first  one  or  two  nights,  as  when  erection  occurs  dur- 
ing sleep  it  may  bring  on  free  hemorrhage  from  the  freshly  cut  surfaces 
of  the  wound. 

A  cut  orifice  will  heal  up  immediately  if  left  to  itself.  This  is  pre- 
vented by  having  the  patient  return  in  two,  four,  eight,  and  twelve  days 


FIG.  73.— Straight  Conical  Steel  Sound  (Short). 


to  allow  the  surgeon  to  pass  a  straight  steel  instrument  (Fig.  73)  through 
the  meatus,  to  keep  the  wound  open  until  its  surfaces  are  covered  with 
epithelium. 

The  meatus  sometimes  bleeds  more  freely  when  the  instrument  is 
passed  for  the  first  time  than  when  it  was  cut,  and  should  be  controlled 
in  the  same  manner.  Another  plan  to  prevent  closure  of  the  wound  is  to 
furnish  the  patient  with  a  hairpin,  with  the  curved  portion  rebent  and 
the  angle  much  increased  in  size,  so  as  to  be  large  enough  when  oiled, 
and  passed  down  the  urethra,  to  lie  with  one  leg  of  the  pin  against  the 
roof  of  the  urethra,  the  other  leg  at  the  bottom  of  the  whole  length  of  the 
wound,  while  the  two  points  are  outside.  The  patient  is  told  to  pass  this 
on  the  night  after  being  cut,  and  on  the  following  two  nights ;  then  to 
skip  a  night  for  two  passages  of  the  hairpin ;  then  to  skip  two  nights  for 
three  passages.  By  the  end  of  this  time  (a  full  fortnight)  the  meatus 
has  often  healed  entirely,  or  so  nearly  that  it  may  be  left  to  itself,  and, 
if  thoroughly  cut  and  healed  open,  it  never  recontracts. 

When  internal  urethrotomy  has  become  necessary  in  the  treatment  of 
a  stricture  of  the  pendulous  urethra  more  distant  from  the  meatus,  one 
of  the  various  special  instruments  devised  for  thjs  operation  is  used. 

The  urethra  is  previously  washed  out  with  a  mild  boric-acid  or  saline 
solution,  and  about  two  drachms  of  a  four-per-cent  solution  of  cocaine  or 
eucaine  are  injected  and  retained  about  ten  minutes. 


STRICTURE   OF  THE   URETHRA. 


137 


The  urethrotome  of  Civiale  represents  a  type  from  which  several  modi- 
fications have  been  constructed  (Fig.  72) ;  the  principle  of  this  instru- 
ment is  shown  in  the  accompanying  figure  (Fig.  74).  The  bulbous 


FIG.  74.— Civiale's  Urethrotome. 

extremity  is  passed  beyond  the  grasp  of  the  stricture,  and  the  concealed 
blade  is  unsheathed  while  the  instrument  is  withdrawn  so  as  to  cut  the 
stricture  from  behind  forward.  This  instrument  or  any  of  its  modifica- 
tions are  applicable  to  strictures  of  a  calibre  not  smaller 
than  16  or  17  French,  and  when  it  is  desired  to  incise 
bands  or  contracted  areas  to  a  limited  extent,  and  pro- 
ceed thereafter  with  dilatation. 

It  must  be  stated  that  cutting  a  stricture  with  any 
instrument  does  not  produce  a  radical  cure,  nor  allow 
the  patient  necessarily  to  dispense  with  a  continual 
use  of  the  sound,  although  such  a  result  may  be  ob- 
tained and  it  should  always  render  it  possible  to  ex- 
tend greatly  the  intervals  between  the  passages  of  the 
sounds. 

Otis'  dilating  urethrotome  is  simple  and  strong. 
It  is  a  modification  of  a  number  of  previous  types, 
so  combined  as  to  form  an  instrument  which  performs 
its  functions  very  accurately.  It  consists  (Fig.  75)  of 
a  shaft,  the  blades  of  which  may  be  separated  by  a 
screw  movement  in  the  handle,  and  a  small  knife, 
which  fits  in  a  groove  of  one  of  the  arms  of  the  dilat- 
ing portion  and  which,  concealed  near  the  distal  end,  is 
exposed  and  brought  into  action  when  its  handle  at 
the  proximal  end  of  the  instrument  is  drawn  out.  A 
dial  plate  in  the  handle  registers  the  degree  of  separa- 
tion of  the  blades. 

In  using  this  instrument,  the  location  and  extent 
of  the  stricture  to  be  cut  are  at  first  definitely  decided 
upon,  with  the  urethrameter  or  bulbous  sound.  Then 
the  urethrotome  is  introduced  (dial  plate  and  knife 
toward  the  roof  of  the  urethra)  so  deeply  that  the  point 
at  which  the  knife  blade  shall  emerge  shall  be  at 
least  three-quarters  of  an  inch  deeper  in  the  ure- 
thra than  the  deepest  limit  of  the  stricture.  This 
is  necessary  in  all  strictures  of  large  calibre;  with- 
out it  the  deepest  parts  of  the  stricture— those  most  distant  from  the 
meatus— are  not  cut.  For  the  lower  blade  of  the  instrument,  in  open- 


FIG.  75.— Otis'  Dilating 
Urethrotome. 


138  VENEREAL,  DISEASES. 

ing,  pushes  away  the  urethra,  making  it  slide  back  from  the  upper 
blade;  so  that,  no  matter  how  accurately  the  meatus  may  be  held 
against  the  shaft  of  the  urethrotome,  the  position  of  the  knife  relatively 
to  the  stricture  slides  forward  proportionately  to  the  amount  of  separa- 
tion of  the  blades,  and  therefore,  when  the  knife  ia  brought  into  ac- 
tion, it  may  commence  the  cut  entirely  in  front  of  the  deepest  (often  the 
tightest)  portion  of  the  stricture,  unless  special  care  is  taken  to  avoid  this 
mistake. 

When  the  instrument  has  been  properly  placed,  the  blades  are  separ- 
ated until  they  mark  the  size  to  which  it  is  desired  to  cut  the  stricture. 
In  cutting,  the  handle  of  the  knife  is  withdrawn  far  enough  to  make  the 
cut  in  all  at  least  half  an  inch  longer  than  it  was  originally  decided  that 
the  stricture  measured.  Now  the  blades  are  to  be  rapidly  approximated, 
and  the  knife  is  returned  to  its  concealment  before  withdrawing  the  in- 
strument. If  several  points  of  constriction  exist  in  the  course  of  a  single 
strictured  area,  they  may  all  be  included  in  a  single  incision  along  the 
roof.  If  multiple  stricture  exists  and  a  considerable  interval  of  healthy 
urethra  separates  them,  they  may  be  cut  at  the  same  sitting,  but  by  differ- 
ent operations,  the  deeper  one  being  cut  first.  The  flow  of  blood  forms 
no  material  impediment  to  cutting  the  second  stricture.  If  the  meatus 
is  to  be  cut,  it  should  be  cut  along  the  floor  as  the  first  step  in  the  opera- 
tion, if  this  has  not  already  been  attended  to  in  the  preliminary  examina- 
tion. No  ether  is  necessary  in  the  performance  of  this  operation.  Co- 
caine or  eucaine  may  be  used,  the  danger  of  cocaine  being  always  borne 
in  mind.  It  should  be  done  slowly,  for  accuracy  and  precision  are  essen- 
tial factors  of  success. 

After  the  cutting  has  been  accomplished,  it  is  well  to  pass  a  bulbous 
or  straight  steel  sound  over  the  cut  region,  to  decide  whether  the  cutting 
has  been  efficient  and  has  thoroughly  relieved  the  constriction. 

If  this  is  found  not  to  be  the  case,  the  urethrotome  should  not  be  rein- 
troduced.  The  second  cut  is  likely  to  pass  through  the  stricture  at  a  differ- 
ent point,  and  a  third  cut  to  take  still  another  route.  Thus  the  stricture 
becomes  partly  cut  in  a  number  of  places,  its  outermost  circle  not  being  cut 
through  anywhere;  and  more  cutting  is  done  than  is  justified  by  the  end 
in  view,  since  each  cut  increases  the  possibility  of  cicatricial  changes. 
The  way  to  avoid  the  necessity  for  a  second  cut  is  to  make  the  first  one 
deliberately,  to  locate  it  accurately,  and  to  make  it  deep  enough.  If  this 
is  not  done,  it  is  wiser  not  to  perform  a  second  operation  until  it  is  deter- 
mined that  dilatation  will  not  accomplish  the  desired  result,  and  not  until 
it  has  been  practised  for  a  sufficient  period  after  the  first  cut  has  healed, 
and  then  to  start  afresh,  as  if  nothing  had  been  done  previously. 

It  remains  to  determine  how  deeply  to  cut  a  given  stricture  of  large 
calibre  in  the  pendulous  urethra.  This  cannot  be  absolutely  decided  by 
any  criterion.  Dr.  Otis,  as  already  stated,  has  fortified  his  followers  with 


STRICTURE    OF   THE   URETHRA.      •  139 

a  scale,  based  upon  an  alleged  constancy  of  relation  between  the  normal 
size  of  the  urethra  and  that  of  the  penis  in  repose;  yet  this  scale  (which 
is  certainly  only  approximate)  does  not  give  its  followers  the  satisfaction 
of  doing  the  whole  operation  at  a  single  cut.  In  many  operations  the 
urethrotome  is  introduced  twice  or  more  often  at  the  same  sitting;  and 
very  frequently  it  is  found,  after  some  days  or  weeks,  that  the  stricture 
has  to  be  cut  over  again.  When  this  method  was  first  taught  it  was  not 
uncommon  to  see  cases  in  which  there  had  been  repetitions  in  the  cutting, 
to  the  extent  of  four  times  at  different  sittings,  and  in  the  same  individual, 
and  that  too  without  resulting  in  a  cure.  Consequently  it  is  rather  idle 
to  attempt  accuracy  by  measuring  so  uncertain  an  organ  as  the  penis,  even 
if  the  scale  possessed  the  accuracy  which  its  inventor  ascribes  to  it;  and 
the  question  remains :  AY  hat  rule,  if  any,  have  we  to  go  by? 

In  answer,  it  may  be  stated  as  a  general  proposition  that  the  strictured 
point  which  will  not  yield  to  dilatation  must  be  cut  so  as  to  be  somewhat 
larger  than  the  normal  urethra  at  that  point ;  and  that,  to  insure  the  best 
results,  a  single  cut  should  be  made — a  cut,  if  possible,  to  pass  beyond  all 
diseased  tissues  and  into  the  healthy  tissue. 

This  result  is  probably  often  attained  by  following  the  measurements 
of  Dr.  Otis,  since  his  estimation  of  the  size  of  the  urethra  is  extreme;  but 
even  his  measurements  will  not  suffice  in  some  cases  in  which  inodular 
tissue  has  involved  the  whole  substance  of  the  corpus  spongiosum,  while 
often  they  are  unnecessarily  high. 

A  fair  rule  to  go  by  is  first  to  establish  the  fullest  size  to  which  the 
normal  rneatus  may  be  distended — the  normal  meatus  not  strictured  and 
without  pockets — and  to  cut  the  stricture,  after  having  screwed  up  the 
urethrotome  to  mark  not  less  than  two  sizes  (American,  three  or  four 
sizes  ».  rench)  higher  than  that  limit.  Should  the  meatus  be  strictured 
congenitally  or  by  disease,  the  surgeon's  judgment  must  guide  him  in  the 
extent  of  his  incision,  both  of  the  meatus  and  of  the  deeper-seated  stric- 
ture, remembering  that  the  normal  meatus  of  the  full  average-sized 
penis  in  the  American  will  range  very  close  upon  20  American  scale  (30 
French).  In  other  words,  a  conical  steel  instrument  of  size  20  will  pass, 
by  its  own  weight,  the  normal  meatus  (without  pockets)  in  the  average 
American  male  taken  at  random,  with  fair-sized  genitals,  or  certainly 
may  be  passed  with  a  little  coaxing,  putting  the  meatus  more  or  less  on 
the  stretch,  without  in  the  least  tearing  or  injuring  it.  A  penis  of  less 
size  will  have  a  more  moderate  urethra,  as  a  rule. 

It  has  been  found  by  experience,  as  Dr.  Otis  has  shown,  that  the 
breadth  of  the  knife  blade  does  not  count,  and  that  if  the  blades  of  the 
urethrotome  be  separated  to  20  and  the  cut  then  made,  the  strictured 
point  will  be  found  to  be  cut  not  above  size  20.  Therefore,  the  limits  of 
cutting  which  are  given  are  quite  moderate,  for  the  meatus  is  normally  the 
smallest  part  of  the  canal,  and  an  incision  at  least  two  sizes  larger,  lower 


140 


VENEREAL  DISEASES. 


0 


down,  is  not  extravagant,  since  the  cut  is  quite  certain  to  lose  oue  size 

while  healing. 

If,  after  healing,  it  is  found  that  the  symptoms  persist,   and  the 
resiliency  of  the  stricture  remaining  shows  that  the  outside  fibres  have 

not  been  cut  through,  then  another 
operation  may  be  performed,  the 
surgeon  being  fortified  by  the 
knowledge  gained  during  the  first 
operation,  and  the  cut  on  the  sec- 
ond occasion  may  be  made  two  or 
even  three  (American)  sizes  larger 
than  before;  but  dilatation  with 
increasing  intervals  should  always 
be  tried  before  recourse  is  had  to  a 
second  cutting. 

When  the  calibre  of  a  stricture 
in  the  pendulous  urethra  is  too 
small  to  admit  the  Otis  urethro- 
tome,  an  effort  should  be  made  to 
dilate  the  narrovv  point  sufficiently 
to  receive  the  instrument.  This 
may  be  done  either  by  the  aid  of  a 
whalebone  guide  and  tunnelled 
sound  or  by  a  preliminary  partial 
urethrotomy  performed  with  a 
slender  instrument  constructed  on 

L  the  Maisonneuve  principle,   to  cut 

from  before  backward.  The  Mai- 
sonneuve instrument  consists  of  a 
curved  conductor,  upon  which  is 
screwed  a  fine  flexible  bougie  as  a 
guide.  A  small  triangular  blade  on 
a  wire  staff  slides  in  the  groove  of 
the  conductor  and  cuts  the  stricture 
from  before  backward.  The  apex  of 
the  blade  is  protected  by  a  blunt 
shield  so  that  the  healthy  part  of 
the  canal  is  distended,  as  the  knife 
is  thrust  along  the  curve  toward  the  stricture,  while  the  latter  is  cut  by  the 
free  edge  of  the  knife.  This  instrument,  which  is  curved,  is  adapted  for 
internal  urethrotomy  beyond  the  bulbous  portion  of  the  urethra.  A  better 
instrument  for  the  pendulous  urethra  is  a  modification  of  the  Maisonneuve, 
known  as  Fluhrer's  (Fig.  77).  This  consists  of  a  grooved  conductor, 
nine  and  a  half  inches  long,  12  French  calibre,  slightly  curved  at  its  distal 


FIG.  70.— Maisonneuve 
Urethrotome. 


FIG.  77.— Fluhrer's 
Urethrotome. 


STRICTURE   OF   THE   URETHRA.  141 

end.  A  triangular  blade  on  the  end  of  a  stylet,  similar  to  that  of  the 
Maisonneuve  instrument,  slides  through  the  groove  of  the  conductor, 
being  protected  at  its  apex  by  a  small  blunt  shield.  This  instrument  will 
incise  the  urethra  up  to  18  to  24  French.  All  strictures  of  the  anterior 
canal  except  when  in  close  proximity  to  the  meatus  should  be  cut  upon 
the  roof,  and  therefore  the  grooved  surface  which  conducts  the  cutting 
blade  of  any  of  the  instruments  described  should  be  turned  toward  the 
roof  of  the  urethra  when  the  stricture  is  in  the  pendulous  urethra. 

Internal  urethrotomy  beyond  the  pendulous  urethra  is  an  operation 
which  has  its  adherents,  but  for  several  reasons  its  adoption  is  not  advised. 
In  the  first  place,  the  bleeding  is  likely  to  be  troublesome  and  much  harder 
to  arrest  than  hemorrhage  from  the  pendulous  urethra.  There  is  certainly 
much  greater  danger  of  septic  infection  when  the  urethra  is  incised  be- 
yond the  cut-off  muscle.  In  fact,  many  deaths  due  to  this  operation  have 
been  recorded,  and  undoubtedly  many  have  occurred  which  have  never 
been  heard  from.  Furthermore,  experience  goes  to  show  that  when  a 
urethra  is  incised  in  the  deeper  region  by  means  of  external  urethrotomy, 
and  proper  drainage  is  afforded  through  the  external  wound,  such  serious 
complications  as  have  frequently  been  known  to  follow  the  operation  of 
deep  internal  urethrotomy  are  seldom  observed.  The  additional  advan- 
tages afforded  by  external  urethrotomy  in  permitting  a  close  inspection  of 
the  strictured  portion,  the  opportunity  to  incise  it  upon  the  floor  as  well 
as  upon  the  roof,  without  going  too  far  beyond  the  limits  of  the  stricture, 
and  of  permitting  the  complete  excision  of  inodular  tissue  where  it  exists, 
not  to  mention  the  benefits  derived  by  the  bladder  and  posterior  urethra 
from  the  free  drainage  this  operation  affords,  are  all  of  obvious  im- 
portance. 

The  bleeding  after  internal  urethrotomy  is  very  variable.  A  deep 
incision  in  one  patient  may  be  attended  by.a  moderate  flow  of  blood,  while 
a  slight  cut  in  another  will  bring  on  profuse  hemorrhage.  In  a  given 
patient,  however,  the  amount  of  hemorrhage  is  proportionate  to  the  num- 
ber and  depth  of  the  cuts.  Generally,  pressure  will  arrest  the  bleeding. 
It  is  best  applied  with  the  fingers  placed  directly  over  the  urethra.  The 
blood  should  be  allowed  to  clot,  and  the  clot  that  forms  and  protrudes 
from  the  meatus  should  be  left  in  place  and  not  be  removed  with  the 
fingers,  for  this  allows  only  a  continuance  of  the  hemorrhage  and  necessi- 
tates the  formation  of  another  clot.  If  the  flow  of  blood  persists,  con- 
tinuous pressure  from  without  may  be  tried  by  applying  a  tight  bandage 
around  the  penis,  or  by  binding  two  small  rectangular  splints,  one  along 
the  urethra  and  the  other  along  the  dorsum,  by  means  of  a  strip  of  adhe- 
sive plaster  and  then  a  narrow  bandage.  This  dressing  may  be  removed 
prior  to  urination  and  reapplied  directly  afterward  until  no  further  bleed- 
ing occurs.  In  some  cases  little  or  no  blood  escapes  at  the  moment  of 
operation,  but  later,  at  the  time  of  the  next  urination  or  during  erection  at 


142  VENEREAL  DISEASES. 

night,  hemorrhage  occurs  which  may  become  quite  profuse.     The  same 
means  will  suffice  to  arrest  it  as  described  above. 

The  after-treatment  consists  in  the  use  of  the  conical  steel  sound  at 
appropriate  intervals.  Until  the  cut  surfaces  of  the  urethra  shall  have 
healed  over,  or  before  the  expiration  of  about  two  weeks,  the  posterior 
canal  should  not  be  entered  by  the  sound.  A  long  straight  steel  sound 
is  well  adapted  for  use  during  this  period  (Fig.  78).  Forty-eight  hours 
after  the  cutting,  a  full-sized  sound — large  enough  to  put  the  meatus  fully 


FIG.  78.— Straight  Conical  Steel  Sound  (Long). 

upon  the  stretch — may  be  gently  introduced.  This  is  followed  by  hemor- 
rhage, sometimes  more  profuse  than  that  which  occurred  at  the  moment  of 
the  operation ;  but  it  yields  more  promptly,  as  a  rule,  and  generally  becomes 
arrested  spontaneously  after  a  few  moments.  It  is  well,  however,  to  exer- 
cise the  precaution  of  tying  the  penis  up  at  night-time  in  a  snug  bandage, 
to  prevent  hemorrhage  during  sleep  on  account  of  erection.  After  another 
interval  of  forty-eight  hours,  the  same  full-sized  sound  may  be  introduced; 
or,  if  the  urethra  be  generally  inflamed  so  that  the  large  size  causes  much 
pain,  one  size  lower  may  be  employed.  Again,  in  seventy-two  hours  the 
process  is  repeated.  The  next  interval  may  be  four  days,  and  the  next  six. 
After  this  one  or  two  passages  of  the  sound,  at  intervals  of  one  week, 
often  terminate  the  case,  although  in  many  instances  a  much  longer  time 
is  necessary,  and  sometimes  one,  two,  or  even  more  sizes  in  the  sound  are 
temporarily  lost,  owing  to  inflammatory  conditions  in  the  urethra  excited 
by  the  mechanical  violence  to  which  it  has  been  subjected;  but  this  may 
be  regained  by  progressive  dilatation  at  longer  intervals  when  the  irrita- 
tion has  subsided.  The  cut  is  known  to  be  healed  when  a  full-sized  in- 
strument can  be  passed  without  being  followed  by  any  blood ;  but  even 
after  this  it  is  wise  to  keep  up  the  use  of  a  full-sized  sound,  at  longer  inter- 
vals, for  some  time. 

If  now  the  symptoms  have  disappeared,  the  sound  may  be  laid  aside, 
and  the  patient  is  and  remains  well,  although  manipulation  with  the 
urethrameter  may  still  detect  that  the  point  cut  is  smaller  than  other 
parts  of  the  urethra.  If  the  symptoms  recur  and  the  stricture  recontracts, 
dilatation  should  be  practised  and  account  taken  whether  or  not  the  symp- 
toms yield,  in  which  case  recontraction  may  be  forestalled  by  noting  the 
interval  after  which  the  symptoms  reappeared,  and  directing  that  the 
instrument  be  used  again  at  about  the  same  interval,  or  when  there  exists 
any  tendency  to  recurring  symptoms. 

t  should  be  borne  in  mind  that  sometimes  the  symptoms  which  persist 
after  a  stricture  has  been  cut  and  the  attendant  irritation  has  had  time  to 


STRICTURE   OF   THE  URETHRA.  143 

subside  may  be  due  to  inflammation  deeper  in  the  canal — posterior-ure- 
thritis — which  necessarily  is  not  relieved  by  the  cutting  of  the  stricture 
and  will  require  appropriate  treatment  later  on.  The  patient  should  be 
apprised  of  this  fact  so  that  he  may  be  saved  a  keen  disappointment  in 
case  he  has  counted  upon  an  absolute  cessation  of  all  symptoms,  notably 
the  discharge. 

The  complications  attending  this  operation  besides  hemorrhage,  which 
can  always  be  arrested  in  the  pendulous  urethra,  are  those  inherent  to 
most  operations  upon  the  canal,  and  due  often  as  much  to  the  after-treat- 
ment by  instruments  as  to  the  cutting  operation.  They  are  urethral 
fever,  epididyruitis,  cystitis,  possibly  prostatic  or  peri-urethral  abscess, 
occasionally  acute  uraemia,  and  pyelo-nephritis.  None  of  these  complica- 
tions is  likely  to  occur  when  strict  cleanliness  has  been  observed,  and 
when  the  posterior  urethra  has  not  been  invaded  until  the  cut  in  the  an- 
terior portion  is  healed.  Another  complication,  not  very  uncommon 
when  the  cut  has  been  deep,  is  the  formation  of  new  inodular  tissue  in 
the  corpus  spongiosum,  causing  painful  erection. and  chordee.  Painful 
erections  often  persist  for  a  long  period  and  curvature  of  the  penis  may 
remain,  but  not  as  a  rule  unless  the  cut  has  been  too  deep. 

All  these  complications  call  for  treatment  when  they  arise,  and  many 
of  them  demand  a  cessation  in  the  employment  of  instruments.  Thus,  the 
cut  is  allowed  partially  to  close,  but  by  dilatation  later  on  sufficient  .dis- 
tention  may  often  be  obtained,  and  a  second  cutting  operation  is  not  neces- 
sarily required.  The  proper  means  to  adopt  to  avoid  complications  after 
urethrotomy  is  to  keep  the  patient  quiet  upon  his  back  for  several  days 
after  he  has  been  cut,  giving  him  plenty  of  bland  diluents  to  drink  and 
enough  bromide  or  anodyne,  if  need  be,  to  keep  down  erections.  Laxa- 
tives may  be  required  while  the  patient  is  in  bed.  Alkalines  and  oil 
of  sandal  wood,  as  administered  in  simple  urethritis,  may  be  of  service, 
and  sometimes  a  mild  antiseptic  or  astringent  injection,  to  keep  the 
canal  clean  and  remove  the  discharge,  may  be  given  if  needed  several 
days  after  the  operation,  after  the  patient  has  been  permitted  to  be 
about  again. 

Divulsion. — This  operation  is  not  at  the  present  day  held  in  favor  by 
most  surgeons  to  such  an  extent  as  internal  urethrotomy,  and  the  authors 
have  practically  discarded  it,  because  it  is  rough  and  unsurgical.  It  has 
the  advantage  over  internal  urethrotomy,  however,  of  calling  for  less 
after-treatment  by  instruments  in  the  urethra,  the  hemorrhage  is  much 
lighter,  and  the  effect  often  lasting.  The  danger  is  certainly  no  greater 
in  this  operation  than  in  internal  urethrotomy  of  the  deep  urethra.  Bige- 
low's  instrument  is  recommended  in  soft  and  yielding  strictures.  It  con- 
sists of  a  shaft  with  an  expanded  extremity  conical  in  shape,  grooved  on 
one  side  to  fit  over  a  slender  metallic  guide,  attached  to  a  flexible  bougie. 
When  the  latter  is  in  place,  the  divulsor  is  wedged  by  force  through  the 


144  VENEREAL,  DISEASES. 

stricture,  and  prevented  from  going  too  far  by  a  shield  on  the  end  of  the 

guide. 

Thompson's  tunnelled  divulsor,  capable  of  being  screwed  up  to  size 
21  American  scale,  is  used  in  tight  strictures  of  the  curved  urethra.  Fig. 
79  a,  represents  the  instrument.  By  turning  the  handle  the  blades 
may  be  separated,  b,  the  amount  of  separation  being  registered  upon  an 
index  in  the  handle.  The  instrument  is  to  be  used  as  follows : 

The  depth  of  the  front  face  of  the  stricture  from  the  meatus  is  at  first 
accurately  ascertained.  Then  a  filiform  whalebone  bougie,  twenty  inches 


FIG.  79. 

long,  must  be  passed  through  the  stricture  until  its  distal  extremity  reaches 
the  meatus,  the  other  end  lying  coiled  up  in  the  bladder  beyond  the  stric- 
ture. The  urethra  having  been  thoroughly  washed  with  warm  boric-acid 
solution  and  anaesthetized  with  a  four-per-cent  solution  of  cocaine  or  eu- 
caine,  retained  five  to  ten  minutes,  the  divulsor  is  well  lubricated,  the 
tunnel  is  threaded  over  the  whalebone  guide,  and,  while  the  tip  of  the 
guide  and  the  end  of  the  penis  are  held  tense  with  one  hand,  with  the 
other  the  divulsor  is  slowly  to  be  pushed  along  over  the  guide  through 
the  stricture  and  into  the  bladder  until  its  point  of  greatest  dilatability 
lies  at  the  centre  of  the  stricture.  The  outside  of  the  divulsor  is  marked 
in  inches  to  facilitate  this  step  in  the  operation. 

It  is  necessary  to  take  every  precaution,  in  guiding  the  divulsor  into 
the  bladder,  not  to  let  it  double  up  the  guide  in  front  of  itself.  To 
guard  against  this,  during  the  whole  time  that  the  point  of  the  divulsor 
is  travelling  the  curved  part  of  the  urethra  the  guide  should  be  pulled  upon 
very  gently,  so  that,  as  the  divulsor  slips  in,  the  guide  is  being  steadily 
pulled  out.  If  too  much  of  the  guide  is  used  in  this  way  at  any  time,  the 
divulsor  being  left  in  place,  the  guide  may  be  again  pushed  forward 
through  the  stricture  and  the  tunnel  until  all  its  excess  is  again  coiled  up 
in  the  bladder,  and  then,  by  coaxing  and  gentle  manipulation  of  the  divul- 
sor while  the  guide  is  being  again  withdrawn,  the  steel  instrument  is 
carried  safely  into  the  bladder,  guided  by  the  whalebone. 

When  the  divulsor  is  in  place,  the  guide  should  be  entirely  withdrawn 
and  the  process  of  divulsion  immediately  commenced.  The  handle  of  the 
divulsor  may  be  turned  slowly  or  rapidly  until  such  a  grade  of  dilatation  has 
beeu  reached  as  shall  have  been  previously  determined  upon,  or  until  blood 


STRICTURE   OF  THE   URETHRA.  145 

begins  to  flow  rather  freely  from  the  meatus,  indicating  that  the  morbid 
tissue  has  been  divulsed — torn  through.  The  stricture  tissue  is  brittle, 
and  although  tough  it  tears  more  easily  than  the  sound  tissue,  the  elas- 
ticity of  which  allows  it  to  escape  any  considerable  injury.  Thus,  the 
process  of  divulsion  effects  about  the  same  result  as  internal  urethrotomy, 
with  the  difference  that  the  torn  tissue  bleeds  less  than  a  similar  wound 
made  with  the  knife  would,  and  has  very  little  tendency  to  heal  up  imme- 
diately; both  of  which  results  are  very  desirable,  since  they  do  away 
with  the  necessity  for  a  considerable  amount  of  after-treatment  which 
might  otherwise  be  required. 

As  the  divulsor  is  being  unscrewed  preparatory  to  its  removal,  its 
handle  should  be  gradually  depressed  between  the  thighs,  and  its  point 
pushed  forward  into  the  bladder  until  the  blades  meet,  when  they  may  be 
safely  withdrawn.  Without  the  exercise  of  this  precaution,  it  sometimes 
happens  that  the  closing  blades  catch  a  portion  of  mucous  membrane — 
either  the  ragged,  torn  edge  of  the  stricture,  or  a  fold  of  membrane 
lower  down  the  urethra,  and  pinch  it  so  tightly  that  the  instrument 
cannot  be  disengaged  by  again  screwing  it  up.  The  little  piece  of  mu- 
cous membrane  in  such  a  case  must,  of  necessity,  be  torn  away  before  the 
instrument  can  be  extricated. 

After  the  divulsor  has  been  withdrawn  the  bleeding  invariably  stops 
promptly,  and  no  other  instrument  should  be  passed  into  the  urethra. 
The  patient  is  simply  put  to  bed  and  told  to  remain  there  from  twenty  - 
four  to  thirty-six  hours,  after  which  he  may  get  up  and  go  about  his 
business.  If  he  has  a  chill,  he  must  be  kept  longer  in  bed,  and  his  tem- 
perature watched  to  see  whether  the  chill  signifies  anything  more  than 
ordinary  urethral  fever. 

The  question  of  urethral  fever,  and  its  treatment  after  operations 
upon  the  urethra,  will  be  discussed  presently. 

After  divulsion  no  instrument  should  be  passed  into  the  urethra  until 
the  lapse  of  from  five  to  eight  days.  The  torn  tissues  do  not  tend  to  unite 
as  a  cut  does,  otherwise  the  after-treatment  is  about  the  same  as  after 
internal  urethrotomy. 

The  possible  complications  following  divulsion  are  the  same  as  those 
liable  to  be  encountered  after  urethrotomy.  Hemorrhage,  however,  does 
not  occur  to  any  extent. 

External  Perineal  Urethrotomy. — This  operation  is  imperatively  called 
for  by  tight  organic  stricture  deeply  situated  in  the  urethra,  under  certain 
circumstances,  such  as  infiltration  of  urine,  perineal  abscess,  numerous 
fistulee,  and  when  the  stricture  is  impermeable  to  an  instrument  passed 
from  the  meatus. 

The  latter  contingency  alone  does  not  necessarily  demand  external 
urethrotomy.  It  is  also  possible  in  such  a  case  to  aspirate  the  bladder 
with  a  fine,  perforated  needle  above  the  symphysis  pubis,  once  or  twice 
10 


146  VENEREAL  DISEASES. 

if  need  be,  and  then  to  try  the  urethra  again  with  a  whalebone  guide. 
Some  traumatic  strictures  also  of  the  deep  urethra  are  excessively  tough 
and  resilient,  so  that  they  will  not  yield  to  attempts  at  dilatation.  These 
must  be  cut,  and  a  much  more  satisfactory  result  may  be  obtained  and  a 
much  safer  procedure  adopted  by  resorting  to  an  external  than  to  an  inter- 
nal section.  Such  a  complication  of  stricture  as  stone  in  the  bladder 
naturally  calls  for  perineal  section,  since  two  maladies  may  thus  be  over- 
come by  a  single  operation. 

Perineal  Section  with  a  Guide. — This  operation  is  a  simple  one,  much 
more  so  than  the  operation  without  a  guide.  Therefore  no  effort  should 
be  spared  that  may  be  necessary  to  effect  the  passage  of  a  tight  stricture 
with  a  filiform  bougie  and  a  guide  introduced,  whereby  the  operation  is 
much  facilitated  and  shortened. 

If  the  stricture  cannot  be  penetrated  and  a  guide  introduced  before 
etherization,  success  may  be  attained  when  the  parts  are  relaxed  and  the 
patient  is  unconscious.  The  preparation  of  the  patient  is  the  same  as  for 
any  operation  in  this  vicinity.  The  parts  should  be  thoroughly  cleansed 
and  shaved,  the  bowels  emptied  by  a  laxative,  and  the  rectum  washed  out 
with  saline  enemata. 

The  guide  having  been  passed,  the  patient  is  bound  in  the  lithotomy 
position.  The  instruments  required  besides  the  common  accompaniments 
of  all  operations,  including  artery  forceps,  scalpels,  etc.,  are  a  straight 
narrow  bistoury,  a  probe-pointed  narrow  bistoury  or  Blizzard  knife  (Fig. 
80),  different  sizes  of  tunnelled  sounds  or  catheters  (Figs.  81,  82),  fili- 
form bougies,  probed  grooved  director,  female  catheter,  and  perineal 
drainage  tube  (Fig.  83). 

In  strictures  of  large  calibre,  when  the  operation  is  to  be  performed 
for  drainage  or  whenever  the  stricture  will  admit  the  passage  of  a  staff 
or  grooved  sound  of  any  size,  by  using  the  largest  size  possible  the  opera- 


FIG.  80.— Probe-Pointed  Bistoury  or  Blizzard  Knife. 


tion  is  rendered  so  much  the  more  easy.  If  a  filiform  bougie  has  been  used 
to  introduce  the  tunnelled  guide,  it  should  be  removed  provided  the  latter 
has  passed  through  the  stricture  and  reached  the  bladder,  which  is  demon- 
strated positively,  when  a  tunnelled  catheter  (Fig.  82)  is  used,  by  with- 
drawing the  stylet  and  obtaining  a  flow  of  urine.  If  this  be  successfully 
accomplished  the  bladder  should  be  emptied  and  washed  with  a  three- 
per-cent  boric  or  boro-salicylic  solution,  a  few  ounces  of  which  is  allowed 
to  remain  in  the  bladder. 

While  the  staff  is  pressed  toward  the  perineum  by  an  assistant,  who 


STRICTURE   OF   THE   URETHRA. 


147 


also  holds  up  the  scrotum,  an  incision  about  two  inches  long  is  made  in 
the  median  raphe,  ending  one  inch  in  front  of  the  anus  and  extending 
through  the  skin  and  fascia.  The  index  finger  is  introduced  into  the 
wound  to  locate  the  groove  on  the  staff ;  a  sharp-pointed  bistoury  is  then 
used  to  incise  the  tissues  overlying  the  in- 
strument, and  by  making  a  clean  slit  in  the 
urethra  its  point  will  enter  the  groove.  The 
probe-pointed  bistoury  is  now  substituted  for 
the  sharp-pointed  instrument,  but  the  latter 
should  not  be  removed  until  the  former  finds 
the  opening  in  the  urethra  and  the  groove  on 
the  guide.  The  probe-pointed  bistoury  is 
now  pushed  along  with  the  staff  toward  the 
apex  of  the  prostate  and  then  withdrawn.  A 
small  female  catheter  is  passed  through  the 
wound  to  the  staff,  which  is  then  withdrawn 
and  the  catheter  thrust  toward  the  bladder 
until  fluid  is  obtained  to  denote  that  the 
right  path  has  been  taken.  A  small  grooved 
director  replaces  the  catheter  upon  which  the 
urethra  may  be  further  incised  upon  the  floor 
and  upon  the  roof,  according  to  the  nature 
and  extent  of  the  stricture.  If  there  also 
exists  stricture  of  the  pendulous  urethra  it 
should  be  cut  with  the  urethrotome.  The 
operation  is  then  completed  by  the  intro- 
duction of  a  perineal  drainage  tube  (Fig. 
83). 

In  those  cases  in  which  the  obstruction  is 
too  tight  or  too  tortuous  to  permit  the  passage 
of  a  tunnelled  catheter  or  staff  through  the 
stricture,  the  operator  passes  the  tunnel  of 
the  catheter  or  sound  over  a  whalebone  bou- 
gie, which  has  been  previously  introduced  as 
a  guide  through  the  obstruction,  and  carries 
it  down  to  the  face  of  the  stricture.  He 
then,  with  the  scrotum  and  testicles  drawn 
well  up  out  of  the  way,  entrusts  the  in- 
strument to  his  assistant,  and  proceeds  to  cut  down  methodically  in  the 
middle  line  layer  after  layer,  aiming  for  the  tip  of  the  sound,  which  of 
course  represents  the  anterior  face  of  the  stricture.  As  soon  as  the  tip 
of  the  sound  has  been  exposed,  a  curved  needle,  threaded  with  silk,  is 
deeply  inserted  on  either  side  through  the  skin  and  deep  tissues,  and 
brought  out  through  the  urethral  mucous  membrane,  just  in  front  of  the 


148  VENEREAL  DISEASES. 

anterior  face  of  the  stricture,  near  the  tip  of  the  sound.  The  needle 
being  removed,  each  ligature  is  knotted  to  itself,  so  as  to  form  a  loop  on 
either  side.  The  loops  are  entrusted  to  two  assistants.  They  form  the 
best  possible  means  of  keeping  the  wound  open  without  the  use  of  fingers 


G.  TIEMANN  &  CO. 

FIG.  82.— Tunnelled  Catheter  on  Filiform  Guide. 

or  instruments,  which  obstruct  the  light  and  allow  the  whole  bottom  of 
the  deep  wound  to  be  freely  inspected,  showing  the  end  of  the  filiform 
guide  disappearing  through  the  stricture  among  the  tissues  which  have 
stopped  the  tip  of  the  tunnelled  instrument. 

It  now  requires  a  little  delicate  dissection  in  the  middle  line,  following 
the  black  filiform  guide,  and  the  obstruction  is  cut  on  the  end  of  the  steel 
instrument.  Care  is  necessary  not  to  cut  off  the  slender  whalebone  in  the 
wound.  The  tunnelled  catheter  may  now  be  easily  slid  forward  into  the 
bladder,  and  the  removal  of  its  stylet  allowing  the  urine  to  flow  freely 
through  it  demonstrates  the  success  of  the  operation. 

The  catheter  should  now  be  withdrawn  and  the  site  of  the  stricture 
examined.  If  this  has  involved  the  roof  as  well  as  the  floor  of  the  ure- 
thra, a  bridge  across  the  roof,  generally  with  a  slight  pocket  above  and 
in  front,  will  be  noticed.  This  should  be  thoroughly  cut  through,  or  it 
may  prove  an  obstacle  to  the  introduction  of  sounds  while  the  wound  is 
healing. 

Bleeding  points  next  require  attention,  and  finally  the  bladder  should 
be  thoroughly  examined  for  stone,  and  the  finger  should  assure  the 
operator  that  all  the  hard,  cicatricial  tissue  constituting  the  stricture  has 
been  thoroughly  cut  through  at  each  end  of  the  wound.  Inodular  tissue 


FIG.  83.— Perinea!  Drainage  Tube. 

should  be  dissected  away  and  excised.  The  divided  ends  of  the  urethra 
may  be  then  brought  together  by  sutures,  or  when  a  large  area  has  been 
removed  the  transplantation  of  mucous  membrane  may  be  attempted. 
This  operative  measure  has  been  conducted  with  success  by  a  few  sur- 
geons.1 The  pendulous  urethra  should  also  be  examined  for  stricture, 
which  should  be  cut  if  found,  which  will  enable  the  surgeon  to  convince 

1  Keyes :  Jour.  Cut.  and  Gen.-Urin.  Diseases,  1891. 


STRICTURE   OP   THE   URETHRA.  149 

himself  that  he  can  easily  pass  a  full-sized  conical  steel  sound  into  the 
bladder  through  the  meatus. 

A  perineal  drainage  tube  is  introduced  so  that  the  eye  of  the  instru- 
ment is  just  within  the  bladder,  and  through  it  the  bladder  is  irrigated 
thoroughly  with  hot  boric-acid  solution ;  or  in  the  case  of  marked  cystitis 
a  solution  of  silver  nitrate,  1  :  4,000.  The  tube  is  held  in  place  by 
tapes  tied  to  the  waistband. 

The  amount  of  bleeding  is  not  generally  considerable  unless  the  bulb 
has  been  slit  during  the  operation,  when  it  is  controlled  by  packing  with 
absorbent  gauze  beneath  the  skin  in  front  of  the  tube.  A  small  packing 
may  also  be  placed  around  the  tube  if  the  hemorrhage  is  such  as  to  call 
for  it.  This  may  be  removed  in  forty-eight  hours  and  replaced  again  if 
need  be. 

Irrigation  twice  daily  with  boric-acid  solution  is  desirable,  and  occa- 
sionally with  silver-nitrate  solution  (1  :  4,000)  if  the  condition  of  the 
bladder  calls  for  it.  At  the  end  of  two  or  three  days  the  tube  should  be 
temporarily  removed  and  a  sound,  one  or  two  sizes  smaller  than  the  full 
size,  should  be  passed,  after  which  the  bladder  should  be  washed  and 
the  tube  replaced. 

After  an  interval  of  another  forty-eight  hours  the  same  sound  is  again 
passed.  Then,  at  intervals  of  three  or  four  days,  the  largest  conical  steel 
sound  that  will  go  should  be  gently  carried  through  the  whole  course  of 
the  urethra  into  the  bladder,  and  this  continued  at  gradually  lengthening 
intervals  until  the  wound  has  healed — a  time  generally  varying  from  three 
to  six  weeks. 

The  tube  is  left  in  the  bladder  generally  for  about  four  days,  after 
which  it  is  removed  permanently,  unless  on  account  of  the  existing  cys- 
titis it  is  desired  to  afford  the  bladder  the  benefit  of  prolonged  drainage, 
in  which  case  it  should  be  left  in  place  for  ten  days  or  two  weeks.  This 
necessarily  makes  a  decided  difference  in  the  period  of  confinement,  which 
is  otherwise  not  generally  over  ten  days  to  two  weeks  and  sometimes  less. 

After  the  tube  is  removed  for  the  first  twenty -four  or  forty -eight  hours 
all  the  urine  passes  away  through  the  perineal  wound,  after  which  it  is 
divided  in  varying  quantity  between  the  perineal  and  the  natural  route. 
As  the  wound  heals,  which  it  generally  does  without  assistance,  the 
urine  gradually  passes  entirely  by  the  natural  route.  This  sometimes 
occurs  as  early  as  at  the  end  of  the  first  week. 

When  the  patient  gets  about  in  from  ten  days  to  two  weeks  his  peri- 
neal wound  requires  little  care  other  than  ordinary  cleanliness  and  the 
protection  of  a  pad  of  absorbent  gauze  held  in  place  by  a  T-bandage. 
If  after  he  is  about  there  still  occasionally  occurs  a  little  leakage  at  the 
perineal  wound,  it  need  cause  no  disturbance  as  it  will  take  care  of  it- 
self, and  the  wound  will  heal  firmly  when  the  patient  regains  his  normal 
physical  tone.  If  a  small  fistula  persists,  it  can  be  successfully  closed  by 


150  VENEREAL  DISEASES. 

injecting  it  with  the  ethereal  solution  of  peroxide  of  hydrogen,  five  per 
cent,  as  used  in  fistulous  tracts  elsewhere  (vide  p.  69). 

Finally,  when  the  patient  gets  well,  he  must  be  taught  to  use  a  full- 
sized  conical  steel  sound  for  himself  at  such  intervals  as  may  be  deemed 
necessary— once  a  month,  once  in  six  weeks,  as  the  case  may  be— just  as 
after  internal  urethrotomy  or  divulsion,  or  his  cure  may  not  be  lasting. 
Many  a  patient  relapses  into  a  condition  of  impermeable  stricture,  after 
having  been  thoroughly  cut  in  the  perineum,  either  because  his  surgeon 
has  not  impressed  him  with  the  necessity  of  using  sounds  or  because  he 
himself  has  been  negligent  in  his  duty. 

But  recontraction  is  not  invariable  after  external  perineal  urethrotomy. 
It  is  possible  after  the  continuous  and  systematic  use  of  sounds  fol- 
lowing this  operation  gradually  to  lengthen  the  intervals  between  the 
passages  and  finally  to  discontinue  them  without  recontraction  of  the  stric- 
ture, but  it  is  a  wise  precaution  in  all  cases  to  advise  the  patient  of  a 
continued  possibility  of  its  recurrence  and  to  urge  him  as  a  safeguard  to 
report  at  long  intervals — once  a  year  or  two — for  exploratory  examination. 

Perineal  Section  without  a  Guide.— This  operation  is  a  formidable  one 
on  account  of  the  element  of  uncertainty  which  it  involves.  Generally 


FIG.  84.— Wheelhouse  Guide. 

speaking,  the  operation  without  a  guide  is  easy  to  a  cool-headed  surgeon, 
only  a  few  minutes  being  required  after  the  front  face  of  the  stricture  is 
exposed  before  a  passage  into  the  bladder  is  obtained ;  but  competent  sur- 
geons have  worked  hours  before  the  bladder  has  been  reached,  and  the 
operation  should  therefore  not  be  undertaken  with  an  undue  amount  of  con- 
fidence, but  with  deliberate  and  painstaking  precision,  and  under  the  most 
favorable  conditions  for  an  abundance  of  light. 

The  operation  calls  for  the  same  preparations  as  if  a  guide  were  to  be 
used.  Besides  the  other  instruments  a  few  fine  probes  and  directors  are 
also  necessary.  A  last  attempt  under  ether  should  always  be  made  to 
pass  a  whalebone  guide.  Failing  in  this,  the  grooved  sound  or  catheter 
or  Wheelhouse  guide  is  introduced  as  far  as  the  front  face  of  the  stricture, 
entrusted,  with  the  scrotum,  to  an  assistant,  a  central  incision  is  made  as 
before,  and  the  point  of  the  sound  exposed.  When  the  Wheelhouse 
guide  is  used  (Fig.  84),  the  incision  is  made  upon  the  groove ;  and  after 
the  urethra  is  opened,  the  staff  is  turned  around  so  as  to  act  as  a  re- 
tractor of  the  upper  end  of  the  wound.  Two  long  silk  threads,  one  on 
each  side  of  the  deep  portion  of  the  wound  to  act  as  retractors,  are  then 
passed  and  the  loops  handed  to  assistants. 

Now  the  operator,  with  fine  whalebone  or  silver  probe,  searches  cau- 
tiously on  the  front  face  of  the  stricture  for  the  way  of  the  urethra  into 


STRICTURE   OF  THE  URETHRA.  151 

the  bladder.  To  aid  him  he  may  enlarge  any  existing  perineal  fistula, 
and  try  by  that  route  to  reach  the  posterior  face  of  the  obstruction  within 
the  urethra. 

Usually  the  best  guide  to  the  bladder  is  a  clear  anatomical  understand- 
ing of  just  where  the  hole  in  the  triangular  ligament  is,  and  in  what  rela- 
tion that  hole  stands  to  the  lower  edge  of  the  subpubic  ligament.  This 
lower  edge  of  the  subpubic  ligament  can  always  be  felt ;  and  beneath  it, 
exactly  in  the  middle  line,  about  three-quarters  of  an  inch  below  the 
symphysis,  varying  a  little  in  different  subjects,  lies  the  hole  in  the  tri- 
angular ligament.  This  hole  is  generally  the  operator's  objective  point. 
The  tendency  is  to  cut  too  much  at  first  and  to  probe  too  little,  until  the 
operator  loses  his  bearing  in  the  solid  mass  of  tissues  matted  together  by 
prolonged  inflammation ;  and  once  fairly  off  the  track,  he  rarely  recovers 
his  position  by  any  other  means  than  accident.  Patient  and  judicious 
probing,  with  a  little  careful  cutting  in  the  anatomical  position  of  the 
closed  urethra,  is  generally  rewarded  with  success ;  the  probe  soon  passes 
on  without  obstruction  for  a  considerable  distance  in  the  direction  of  the 
bladder,  another  probe  may  be  pushed  alongside  of  the  first,  and  a  separa- 
tion of  these  two  allows  a  little  bloody  urine  to  flow  out.  The  tight  ring 
surrounding  the  probes  may  now  be  carefully  followed  up  with  the  knife 
for  a  short  distance,  the  area  of  the  canal  widens,  a  female  catheter  passes 
readily  alongside  the  probes,  and  a  gush  of  bloodless  urine  through  it  an- 
nounces that  the  bladder  has  been  reached. 

One  of  the  most  common  causes  of  failure  in  this  operation  is  the  ex- 
istence of  a  false  passage,  starting  from  the  front  face  of  the  stricture, 
the  result  of  some  former  rude  attempt  to  pass  the  stricture  with  a  solid 
instrument.  The  surgeon  may  be  led  far  astray  by  such  a  false  route, 
and  find  his  mistake  only  after  he  has  hopelessly  lost  his  bearings  among 
the  diseased  tissues.  It  is  well,  therefore,  not  to  follow  up  any  inviting 
sinus  without  first  dilating  it  a  little  and  learning  whether  it  leads  in  the 
proper  direction. 

After  the  bladder  has  been  reached,  the  operation  of  perineal  section, 
with  and  without  a  guide,  are  one  and  the  same.  Description  of  the  re- 
maining steps  is  therefore  unnecessary,  since  they  have  been  already  given. 

The  other  surgical  procedures  which  have  been  resorted  to  when  the 
bladder  is  greatly  distended  by  acute  retention  in  the  case  of  impermeable 
stricture  are  aspiration  of  the  bladder,  retrograde  catheterism,  and  Cocks' 
operation. 

Aspiration  of  the  Bladder. — This  should  be  conducted  under  strict 
antiseptic  precautions  in  the  suprapubic  region.  The  restricted  area 
through  which  the  needle  should  be  passed  is  limited  to  one  inch  above 
the  brim  of  the  pelvis,  and  about  one  inch  on  either  side  of  the  median 
line.  This,  however,  is  ample  space  for  a  sufficient  number  of  punctures 
to  carry  a  case  for  several  days. 


152  VENEKEAL,  DISEASES. 

This  operation  is  resorted  to  as  a  palliative  measure  in  impassable 
stricture  with  retention,  and  may  be  followed  by  a  decrease  in  the  en- 
gorgement of  the  tissues  surrounding  the  stricture  sufficient  to  permit  the 
passage  of  a  small  bougie  or  catheter,  and  thus  open  the  way  for  a  subse- 
quent external  urethrotomy  with  a  guide  or  for  progressive  dilatation. 
Cases  are  recorded  in  which  on  account  of  extensive  prostatic  hypertrophy 
the  bladder  could  not  be  reached  in  the  above  manner. 

Retrograde  catheterism  is  performed  from  the  bladder  through  an 
opening  made  above  the  pubis,  in  order  to  reveal  the  opening  of  the 
urethra  during  a  perineal  section,  when  complete  obliteration  has  oc- 
curred and  a  prolonged  effort  to  find  the  distal  end  of  the  canal  has  been 
unsuccessful. 

Cocks'  operation  is  perineal  section  proper,  in  which  no  guide  of  any 
kind  is  employed,  not  even  down  to  the  face  of  the  stricture. 

With  the  finger  introduced  into  the  rectum  a  "  boutonniere  "  incision  is 
made  toward  the  apex  of  the  prostate,  trusting  to  the  deftness  and 
anatomical  accuracy  of  the  operator  to  strike  the  urethra  at  this  point. 
If  the  attempt  be  successful,  a  cannula  is  introduced  into  the  bladder  and 
retained  several  days,  in  the  hope  that  by  the  relief  thus  afforded  the 
swelling  and  induration  about  the  stricture  will  subside  to  a  sufficient 
extent  to  permit  the  passage  of  a  small  instrument  through  the  contracted 
area,  which  if  successful  may  be  followed  up  by  division  of  the  stricture 
or  progressive  dilatation  as  may  be  deemed  expedient. 

Extravasation  of  Urine. — Extravasation  usually  occurs  as  a  result  of 
rupture  of  the  urethra  during  a  violent  straining  effort  to  overcome  the 
resistance  of  a  tight  stricture.  The  urine  is  forced  into  the  surrounding 
tissues,  being  limited  in  its  course,  according  to  the  site  at  which  the 
rupture  occurs,  by  the  anatomical  attachment  of  the  fascise  enveloping  the 
different  regions.  Thus  when  rupture  occurs  in  the  pendulous  urethra  it 
is  followed  by  swelling  of  the  penis,  which  may  be  limited  within  the 
fascia  surrounding  the  corpus  spongiosum,  or,  overcoming  the  resistance 
of  this  membrane,  may  extend  into  the  connective  tissues  of  the  penis 
and  scrotum.  This  form  of  extravasation  is  rare. 

Extravasation  of  urine  in  front  of  the  triangular  ligament  through  the 
bulbous  portion  of  the  urethra  is  limited  by  the  attachments  of  this  fascia 
and  cannot  reach  the  pelvic  cavity  or  the  tissues  of  the  lower  extremity, 
but  is  directed  upward  over  the  hypogastrium  sometimes  to  a  considerable 
extent. 

Rupture  of  the  urethra  in  the  membranous  portion  is  limited  by  both 
layers  of  the  triangular  ligament,  and  on  account  of  the  great  tension  in 
this  limited  space  due  to  the  strong  resistance  offered  by  the  fibrous  tis- 
sues, may  lead  to  suppuration  and  ulceration  and  a  consequent  fistulous 
tract  through  one  or  the  other  layers  of  the  ligament  into  the  pelvis  or 
toward  the  perineum. 


STRICTURE  OF  THE  URETHRA.  153 

Finally  rupture  of  the  urethra  behind  the  triangular  ligament  may 
lead  to  extravasation  around  the  rectum  in  the  periprostatic  region,  or 
going  above  the  prostate  may  extend  into  the  cellular  tissues  of  the  pelvis. 

The  symptoms  of  extravasation  of  urine  depend  upon  the  locality  in 
which  the  rupture  of  the  urethra  has  occurred.  The  condition  is  self- 
evident  when  the  extravasation  occurs  in  front  of  or  behind  the  triangu- 
lar ligament,  provided  the  quantity  of  infiltrated  fluid  be  sufficient  to 
attract  notice;  otherwise  it  may  pass  undetected  until  other  symptoms 
occur.  Sometimes,  however,  the  patient  complains  of  having  felt  some- 
thing give  way  during  a  straining  effort,  followed  by  a  certain  sense  of 
relief,  which  is  unaccompanied  by  the  normal  passage  of  the  urine.  Ex- 
travasation between  the  layers  of  the  triangular  ligament  may  not  be 
recognized  until  further  extension  of  the  process  occurs  or  until  the  onset 
of  constitutional  symptoms.  These  symptoms  consist  of  great  depression 
and  weakness,  pyrexia  and  vomiting,  sometimes  chills ;  and  if  the  condi- 
tion continues  unrelieved,  the  vomiting  continues,  the  pyrexia  increases, 
delirium  ensues,  and  death  may  result  from  ursemic  coma  or  septicaemia. 
The  local  symptoms  consist  of  swellings  in  the  region  to  which  the 
extravasation  has  extended,  the  scrotum  may  be  much  enlarged,  and  the 
tissues  over  the  hypogastrium  and  perineum  may  be  tense  and  red  or 
bluish  and  dusky  and  oedematous.  Actual  destruction  of  the  tissues  may 
occur  as  a  result  of  sloughing  or  gangrene.  The  scrotum  sloughs  entirely, 
leaving  the  testicles  bare.  The  more  septic  the  urine  in  cases  of  extrava- 
sation the  more  rapid  is  the  occurrence  of  the  systemic  symptoms  and  the 
more  profound  the  resulting  septicaemia. 

Urinary  Fistula. — Small  quantities  of  urine  sometimes  escape  from 
the  urethra,  resulting  in  urinary  abscess  and  the  formation  of  fistula. 
Such  abscess  cavities  may  persist  for  a  long  time,  communicating  with 
the  urethra.  When  this  outlet  becomes  closed,  a  fistulous  opening  is 
formed  in  one  or  more  places — through  the  perineum,  backward  into  the 
rectum,  or  in  front  of  the  scrotum. 

The  Treatment  of  Extravasation  and  Urinary  Fistula. — Extravasation 
of  urine  should  be  met  at  once  by  active  operative  measures.  In  the  first 
place  the  tissues  involved  should  be  drained  by  a  sufficient  number  of 
incisions  to  relieve  distention,  and  a  proper  exit  for  the  urine  should  be 
provided  by  perineal  drainage  of  the  bladder,  leaving  the  stricture  alone 
until  the  constitutional  symptoms  subside,  and  the  engorgement  of  the 
tissues  is  removed  as  a  result  of  the  drainage  established.  Local  cleanli- 
ness and  antisepsis  should  be  employed  to  disinfect  the  decomposing  tis- 
sues, and  such  internal  medication  should  be  resorted  to,  in  the  form  of 
stimulants  and  supporting  agents,  as  will  aid  in  sustaining  the  vital 
powers  until  the  septic  poison,  which  has  disorganized  the  system,  shall 
have  been  eliminated. 

The  treatment  of  urinary  abscess,  whether  or  not  it  is  accompanied  by 


154  VENEREAL  DISEASES. 

an  external  fistula,  should  consist  in  the  formation  of  an  external  opening 
as  a  means  of  drainage,  and  of  the  establishment  of  the  proper  calibre  of 
the  urethral  canal  by  dilatation  or  urethrotomy.  Urinary  fistula,  if 
found  during  an  operation  of  external  urethrotomy  or  perineal  drainage, 
should  be  thoroughly  scraped  or  cauterized.  In  many  instances  urinary 
fistulae  will  close  spontaneously  after  the  pre-existing  stricture  has  been 
properly  dilated;  but  it  often  becomes  necessary  to  assist  the  healing 
process  and  for  this  purpose  stimulating  applications  have  been  used  in 
the  form  of  nitrate  of  silver,  carbolic  acid,  or  tincture  of  iodine.  Another 
method — and  one  which  has  proved  satisfactory  in  the  hands  of  the 
authors — is  the  use  of  one  of  the  ethereal  solutions  of  peroxide  of  hy- 
drogen, as  employed  in  the  treatment  of  fistula  in  connection  with  peri- 
urethral  abscess.  Some  fistulous  tracts,  which  have  existed  for  long 
periods,  are  tortuous  in  their  course,  and  surrounded  by  induration, 
may  require  extensive  plastic  work  before  they  become  permanently 
healed. 

Urethral  or  Urinary  Fever. — Urethral.or  urinary  fever  is  one  of  the 
accidents  or  complications  which  arise  in  connection  with  instrumental 
interference  with  the  urethra.  The  phenomena  constituting  this  condi- 
tion may  be  trifling  or  excessively  severe.  The  simple  passage  of  a 
catheter,  the  introduction  even  of  a  single  smooth  sound,  has  been  fol- 
lowed by  death  within  twenty-four  hours,  the  patient  dying  with  a  high 
temperature  following  a  chill  of  varying  severity  and  duration. 

Septic  absorption  along  the  urinary  tract  is  accused  most  commonly 
of  being  the  cause  of  urethral  fever,  but  this  element  alone  is  not  the 
only  causative  factor  of  the  condition  in  question.  The  position  of  the 
lesion,  the  condition  of  the  kidneys,  and  individual  idiosyncrasy  have 
more  to  do  with  the  production  of  urinary  fever  than  the  condition  of  the 
urine,  be  it  ever  so  septic.  The  use  of  instruments  upon  some  persons 
of  a  strongly  timorous  and  neurotic  nature  sometimes  gives  rise  to  pro- 
nounced reflex  symptoms. 

Thus  after  some  trivial  manoeuvre — the  passage  of  a  sound  or  catheter 
—the  patient  becomes  suddenly  pale  and  faint,  sometimes  losing  con- 
sciousness. This  same  con-dition  occurring  in  an  individual  who  is  the 
subject  of  kidney  disease  has  been  known  to  be  followed  by  cessation  of 
the  urinary  function  (anuria)  and  death  from  collapse.  These  phenomena, 
strictly  speaking,  do  not  belong  to  the  condition  known  as  urinary  fever, 
but  are  more  properly  considered  as  a  form  of  shock. 

Chronic  inflammation  of  the  bladder  and  urethra  and  abrasions  of  the 
mucous  membrane  are  predisposing  factors.  The  harsh  manipulation  of 
instruments  seems  to  act  as  an  exciting  cause,  as  does  also  the  septic 
condition  of  the  urine.  Not  one  of  these  conditions  alone  is  sufficient  to 
bring  on  an  attack.  The  bacillus  coh  communis  is  thought  to  be  a  com- 
mon microbic  factor,  but  Rovsmg  has  cast  great  doubt  upon  this  allega- 


STRICTURE   OF  THE  URETHRA.  155 

tion.  Other  pathogenic  organisms  probably  also  exercise  their  morbific 
influence.  Operations  and  explorations  upon  the  pendulous  urethra  and 
upon  the  bladder  are  rarely  attended  by  urinary  fever;  the  curved  ure- 
thra is  vastly  the  most  vulnerable  portion. 

Guyon  recognizes  three  forms  of  urinary  fever — one  characterized  by 
a  sudden  and  sharp  attack,  rapid  in  its  course  and  generally  single ;  second, 
an  attack  which  is  prolonged  or  repeated,  often  very  intense,  and  which 
may  be  accompanied  by  remissions ;  and  third,  a  chronic  form  of  irregular 
duration,  with  or  without  exacerbations.  The  acute  attack  of  urinary 
fever,  or  the  first  type  of  the  acute  form  of  Guyon,  is  characterized  by  a 
sharp  chill;  sometimes  only  chilly  sensations,  at  others  accompanied  by 
marked  rigors.  The  duration  of  the  chill  is  variable,  generally  twenty 
or  twenty-five  minutes,  sometimes  longer.  This  is  followed  by  fever, 
with  an  elevation  of  temperature  of  102°  to  104°  F.,  pulse  110  to  130, 
possibly  irregular,  respirations  more  or  less  labored,  succeeded  by  sweat- 
ing and  general  defervescence.  Such  an  attack  may  occur  with  increased 
severity,  the  temperature  running  from  104°  to  106°  F.,  or  higher,  and 
the  systemic  symptoms  being  correspondingly  more  severe.  There  is 
generally  a  diminution  in  the  secretion  of  the  urine  and  in  severe  cases 
complete  suppression,  which,  if  not  relieved,  may  culminate  in  acute 
uraemia  and  death.  If  the  kidneys  are  sound,  a  desperate  attack  does  not 
necessarily  entail  a  fatal  issue ;  if  the  kidneys  are  diseased,  the  prognosis 
is  much  more  grave.  It  is  probable  that  a  disorganized  condition  of  the 
kidneys  is  responsible  for  the  profound  symptoms  in  most  severe  cases, 
but,  on  the  other  hand,  diseased  kidneys  do  not  necessarily  render  a  pa- 
tient unfitted  for  operation  or  prone  to  urethral  fever.  Many  severe  oper- 
ations are  done  from  necessity  upon  the  urethra  and  bladder  of  patients 
known  to  have  defective  kidneys,  and  they  seem  to  escape  without  chill. 
Operations  upon  the  deep  urethra,  when  no  perineal  drainage  has  been 
established,  are  especially  liable  to  be  followed  by  severe  urethral  fever. 

The  chronic  form  of  urethral  fever  occurs  in  those  who  have  chronic 
cystitis,  atonied  bladder,  dilatation  of  the  ureters  and  pelves  of  the  kid- 
neys. The  attack  is  generally  more  or  less  continuous,  with  exacerbations 
of  chill  and  fever  and  gradual  loss  of  vitality.  If  relief  be  not  afforded, 
or  if  some  additional  source  of  irritation  be  introduced,  such  as  instru- 
mental violence  to  the  deep  urethra,  an  acute  suppression  of  urine  may 
suddenly  ensue  and  lead  to  a  fatal  issue.  This  condition  is  particularly 
liable  to  be  associated  with  chronic  cystitis  the  result  of  prostatic  hyper- 
trophy, and  the  introduction  of  a  catheter  for  the  first  time  without  proper 
precautions  is  often  responsible  for  its  production.  The  prognosis  under 
such  circumstances  is  exceedingly  grave.  When  it  occurs  in  connection 
with  chronic  cystitis  behind  an  old  and  tight  stricture,  the  symptoms  may 
be  somewhat  the  same  as  in  prostatic  hypertrophy;  but,  occurring  in 
younger  men,  the  prognosis  is  not  so  grave. 


156  VENEREAL  DISEASES. 

Treatment.— The  prophylaxis  of  urinary  fever  calls  for  the  most  gentle 
instrumental  manipulation  in  connection  with  operations  or  operative  man- 
oeuvres upon  the  urethra  and  bladder  and  a  careful  disinfection  of  all 
instruments  employed.  It  is  also  important  to  make  a  careful  urinary 
study  of  all  cases  under  examination,  in  order  to  learn  the  condition  of  the 
bladder  and  of  the  kidneys.  Internal  medication  as  a  preventive  means 
is  also  useful  previous  to  an  examination  or  operation  for  stricture.  The 
sulphate  of  quinine  was  formerly  employed  in  full  doses  for  this  purpose, 
but  is  not  at  the  present  day  relied  upon,  being  commonly  replaced  by 
one  of  the  internal  antiseptics.  Salol,  from  grs.  xxx.-lx.,  may  be  given 
several  days  before  and  for  several  days  following  an  operation.  Boracic 
acid,  from  grs.  xxx.-l.  daily,  is  also  used,  or  urotropin,  grs.  viiss.  three 
times  a  day.  At  the  time  of  the  occurrence  of  a  urinary  attack  during  the 
chill  the  patient  should  be  thoroughly  covered,  surrounded  with  hot-water 
bottles,  and  given  a  hot  drink.  The  mild  attacks  are  generally  of  only  a 
transient  nature,  and  the  patient  suffers  from  no  serious  after-effect.  It 
is  only  when  severe  symptoms  occur,  such  as  great  depression,  extreme 
pyrexia,  acute  and  continued  suppression  of  urine,  that  active  thera- 
peutic measures  have  to  be  resorted  to.  If  there  be  evidence  of  acute 
inflammation  of  the  kidneys  the  application  of  cups  to  the  loins  and 
hot  vapor  baths  are  indicated,  but  the  most  important  symptom  to 
note  and  overcome  is  the  incomplete  functional  activity  of  the  kidneys, 
amounting  sometimes  to  positive  suppression.  For  this  condition  one  of 
the  most  reliable  and  satisfactory  resources  is  the  copious  ingestion  of 
some  diuretic  mineral  water,  such  as  Poland,  Stafford,  Bethesda,  Suwan- 
nee,  etc.  This  measure  alone  often  results  in  starting  the  activity  of  the 
urinary  organs  and  in  aiding  them  gradually  to  resume  their  normal 
function.  Urotropin,  which  has  already  been  referred  to  (p.  94)  as  an 
internal  antiseptic,  has  proved  in  the  author's  hands  to  be  a  valuable 
agent  for  post-operative  suppression  of  urine.  Its  action  in  this  in- 
stance is  probably  due  to  its  germicidal  effect.  It  should  be  given  in 
gr.  viiss.  doses,  repeated  three,  four,  or  six  times  in  twenty -four  hours. 
Sometimes  the  effect  is  most  satisfactory.  The  use  of  active  diuretics 
is  not  generally  advisable,  as  they  are  liable  to  exercise  an  irritating  in- 
fluence upon  the  kidneys.  The  infusion  of  broom  and  the  liquor  am- 
monise  acetatis  may  be  given,  and  possibly  render  some  service,  but  in 
the  majority  of  cases  we  believe  that  the  greatest  reliance  is  to  be  placed 
upon  the  copious  draughts  of  diuretic  mineral  water,  a  mild  diet,  prefer- 
ably of  milk,  and  the  administration  of  urotropin.  In  weak  and  en- 
feebled conditions  stimulation  and  tonics  are  called  for.  Under  this 
regime  the  milder  cases  will  always  recover,  and  many  of  those  which  ap- 
pear very  severe  at  the  onset  and  during  the  attack.  Those  cases  that 
suffer  from  disorganized  and  diseased  kidneys  are  often  beyond  reach  of 
any  reparative  measures. 


CHAPTER  VII. 

GONORRHQEAL    RHEUMATISM— NON-SPECIFIC    AFFECTIONS 
OF  THE  EYE— PURULENT   OPHTHALMIA. 

GONORRHOEA!,    RHEUMATISM 

OCCURS  as  a  complication  of  gonorrhoea  in  both  sexes.  It  is  also  found 
in  connection  with  purulent  ophthalmia.  It  is  much  more  common  in 
men  than  in  women,  and  occurs  at  all  ages.  It  bears  no  relation  to 
ordinary  rheumatism,  usually  involves  the  joints,  but  may  attack  the 
tendon  sheaths,  muscles,  structures  of  the  eyes,  bursae,  and  nerves. 
Cases  of  gonorrhoeal  pericarditis,  endocarditis,  and  meningitis  are  also 
recorded.  Its  frequency  as  a  complication  of  urethritis  is  not  great, 
being  between  two  and  three  per  cent  of  all  cases.  According  to  the 
statistics  tabulated  by  various  authors  the  different  joints  are  affected 
in  about  the  following  order  of  frequency :  Knee,  ankle,  wrist,  fingers, 
elbow,  shoulder,  hip,  etc.  It  is  more  often  polyarticular  than  monartic- 
ular.  It  rarely  occurs  early  in  the  course  of  urethritis,  being  usually 
a  late  complication.  It  has  been  observed  as  early  as  the  fifth  or  sixth 
day  of  the  discharge,  but  such  a  case  is  exceptional.  It  is  more  likely  to 
come  on  after  the  second  or  third  week,  and  is  often  seen  two  and  three 
months  after  the  onset  of  the  urethral  inflammation.  Its  cause  is  the 
toxsemic  effect  of  the  gonococcus  upon  the  system,  either  directly  by  its 
presence  in  the  circulation  or  of  the  toxins  derived  from  this  micro- 
organism; or  by  one  or  the  other  of  these  morbid  agencies,  plus  the 
action  of  the  ordinary  pyogenic  microbes  in  the  circulation,  the  gonococcus 
having  prepared  the  way  for  their  entrance.  The  gonococci  are  not  in- 
variably found  in  the  fluid  obtained  from  the  inflamed  joints.  It  is 
believed  that  when  the  gonococci  themselves  are  present,  the  character 
of  the  inflammation  is  fibrous  and  plastic;  that  when  the  joint  effusion 
is  purulent,  pyogenic  organisms  are  present.  The  pathological  lesion  in 
the  joints  consists  of  a  synovitis,  which  may  be  serous,  plastic,  or  puru- 
lent. A  common  form  of  this  malady  is  hydrarthrosis,  which  often 
attacks  the  knee-joint.  It  generally  occurs  on  one  side,  assumes  a 
chronic  form,  and  shows  a  tendency  to  relapse  during  subsequent  attacks 
of  urethritis. 

Symptoms. — There  is  nothing  distinctly  characteristic  in  the  symptoms 
of  gonorrhoeal  rheumatism.  The  condition  may  be  acute,  subacute,  or 
chronic.  The  local  manifestations  may  be  monarticular  or  polyarticular. 


158  VENEREAL   DISEASES. 

When  the  affection  is  acute  and  a  single  joint  is  involved,  for  example 
the  knee,  the  joint  becomes  swollen  and  painful  as  in  ordinary  rheuma- 
tism, and  there  may  be  some  slight  febrile  symptoms.  Local  pain  is 
decidedly  increased  by  moving  about.  When  the  effusion  is  of  a  plastic 
character  the  symptoms  are  more  marked;  and  still  more  so  when  the 
inflammation  becomes  purulent.  In  polyarticular  gonorrhoeal  rheumatism 
the  symptoms  are  not  increased  in  proportion  to  the  number  of  joints  in- 
volved, and  the  intensity  of  the  inflammation  is  not  more  marked  in  this 
form  of  the  malady. 

The  symptoms  of  gonorrhoeal  rheumatism  may  be  very  mild,  simply 
amounting  to  a  little  stiffness  of  the  joints  on  moving,  especially  in  the  ' 
morning.  On  the  other  hand,  a  much  more  intense  condition  may  arise, 
occasioning  considerable  spontaneous  pain  in  the  affected  joints,  with 
redness  of  the  skin  and  swelling,  presenting  all  of  the  features  of  ordi- 
nary rheumatic  gout.  The  affection  generally  tends  in  a  few  days  to 
become  subacute  in  character  and  then  to  assume  its  customary  march, 
which  is  one  of  tiresome  chronicity.  It  is  usual  for  several  joints  to 
become  involved  consecutively,  but  the  trouble  continues  in  the  old  joints 
and  does  not  leave  them  when  the  new  ones  are  invaded. 

Another  form  assumed  by  gonorrhceal  rheumatism  is  inflammation  of 
the  muscles,  sheaths  of  tendons,  bursae,  and  nerves.  These  affections 
also  tend  to  become  chronic,  a  number  of  weeks  or  even  months  some- 
times elapsing  before  they  are  brought  under  control.  The  bursse  most 
often  implicated  are  located  under  the  tendo  Achillis,  under  the  inferior 
tuberosity  of  the  os  calcis,  in  front  of  the  patella,  and  behind  the  olec- 
ranon.  These  tendon  and  bursal  affections  may  assume  an  acute,  sub- 
acute,  or  chronic  character,  and  are  apt  to  be  found  complicating  the 
polyarticular  form  of  gonorrhceal  rheumatism. 

The  diagnosis  of  gonorrhoeal  rheumatism  depends  upon  the  pre-exist- 
ence  of  urethral  inflammation,  which  would  naturally  suggest  the  nature 
of  the  malady,  the  mild  systemic  reaction  and  febrile  disturbance  as  com- 
pared with  acute  inflammatory  rheumatism,  and  the  tendency  of  the  af- 
fection to  become  chronic.  There  being  no  connection  with  ordinary  rheu- 
matism the  rheumatic  diathesis  is  likely  to  be  absent.  The  larger  joints  are 
favorite  sites  of  this  malady,  and  hydrarthrosis  is  a  not  uncommon  form. 

Prognosis.— As  already  stated,  the  general  tendency  of  this  malady  is 
toward  chronicity,  relapses  occurring  in  connection  with  subsequent  at- 
tacks of  urethral  inflammation.  The  duration  of  the  active  period  of  the 
disease  is  generally  rather  long,  and  increased  in  proportion  to  the  num- 
ber of  joints  attacked.  When  the  effusion  is  plastic  or  aero-purulent  the 
case  becomes  thereby  so  much  the  more  protracted  and  the  function  of  the 
joints  is  more  likely  to  become  impaired  or  abolished. 

Cardiac  complications  are  alway  serious  and  may  lead  to  a  fatal  issue. 

Treatment— The  treatment  of  gonorrhoeal  rheumatism  comprises  meas- 


NON-SPECIFIC   AFFECTIONS   OF   THE   EYE.  159 

ures  directed  against  the  urethral  inflammation  and  those  which  are 
applied  to  the  arthritic  complication.  It  is  most  important  that  the 
urethral  condition  should  be  properly  treated,  as  upon  the  success  of  such 
treatment  may  depend  the  improvement  in  the  rheumatic  affection. 
Nitrate  of  silver  is  a  favorite  local  application  for  the  urethra,  and  if 
there  be  a  free  amount  of  purulent  secretion,  either  forward  in  the  ure- 
thra in  the  form  of  a  discharge  or  backward  into  the  bladder  as  shown  by 
the  urine,  irrigations  of  nitrate  of  silver  into  the  bladder,  1 : 4, 000,  or  of 
the  permanganate  of  potassium,  1:6,000,  or  of  corrosive  sublimate, 
1:12,000,  may  prove  more  effective  than  instillations  of  silver,  which 
are  generally  more  suited  to  cases  in  which  the  focus  of  the  urethral 
trouble  appears  to  be  confined  to  a  small  area.  In  the  latter  instance  the 
nitrate  of  silver  in  the  form  of  deep  urethral  instillations  by  the  method 
already  described  in  the  section  on  chrunic  urethritis  may  prove  satis- 
factory. Balsams  and  alkalies  are  of  little  value.  Opium  should  be  given 
in  some  form  if  the  pain  demands  it.  Salicylate  of  sodium,  oil  of  gaul- 
theria,  or  iodide  of  potassium  may  be  given  in  proper  doses,  sometimes 
with  apparent  benefit.  The  plan  of  drinking  freely  of  a  diluent  mineral 
water  is  the  best  means  of  correcting  the  tendency  of  the  urine  to  become 
scanty  and  highly  concentrated.  The  local  measures  called  for  by  the 
joint  itself  consist,  in  the  first  place,  in  absolute  rest.  Cold  evaporating 
lotions  in  most  cases  and  flaxseed  poultices  in  others  are  suitable  expedi- 
ents and  the  means  of  securing  a  certain  degree  of  comfort.  When  the 
acute  condition  has  subsided,  the  remaining  trouble  in  the  joints,  tendons, 
and  bursae  should  be  treated  by  friction,  massage,  galvano-cautery,  electro- 
massage,  dry  heated  air,  blisters,  and  such  other  methods  as  are  generally 
resorted  to  for  the  removal  of  inflammatory  deposits  and  the  treatment  of 
dry  arthritic  conditions  under  other  circumstances.  Suppuration  in  the 
joint  may  require  aspiration  or  drainage,  and  may  ultimately  end  in  im- 
pairment of  the  joint  structure  and  lead  to  permanent  ankylosis. 

NON-SPECIFIC  AFFECTIONS  OF  THE  EYE 

During  the  course  of  polyarticular  gonorrhceal  rheumatism  or  alternat- 
ing with  it,  during  different  attacks  of  urethral  inflammation,  affections 
of  the  eye  have  also  been  noted.  They  involve  the  iris,  conjunctiva, 
sclera,  and  cornea.  These  ocular  affections  are  in  no  sense  due  to  con- 
tagion, but  occur  in  the  same  manner  as  the  arthritic  inflammations  and 
appear  as  complications  of  them.  They  get  well  without  compromis- 
ing the  structure  of  the  eye  or  its  function,  but  are  liable  to  relapse  dur- 
ing subsequent  attacks  of  urethral  inflammation.  When  the  eye  is 
attacked  by  this  non-purulent  form  of  inflammation  in  conjunction  with 
urethritis,  the  cornea  becomes  somewhat  cloudy  and  is  apt  to  grow  more 
prominent  from  overdistention  with  fluid.  The  iris  is  likely  to  be  the 


VENEREAL  DISEASES. 

main  seat  of  the  trouble,  although  it  does  not  show  much  change  in  color. 
The  pupil  may  be  slightly  dilated  and  irregular  or  normal.  The  move- 
ments of  the  iris  are  partially  or  entirely  abolished.  The  conjunctiva 
alone  may  be  the  seat  of  an  injection,  which  is  marked  by  a  slight  redness 
and  swelling,  some  uneasiness,  or  perhaps  by  no  pain  at  all,  and  a  scanty 
muco-purulent  discharge.  This  should  not  be  confounded  with  the  viru- 
lent contagious  form  or  ophthalmia.  All  of  these  affections  of  the  eye  are 
distinguished  from  the  virulent  form,  due  to  contact  with  gonorrhoeal 
pus,  by  the  great  intensity  of  the  symptoms  in  the  latter  malady. 

The  treatment  of  the  eye  affections  which  occur  as  complications  de- 
pends upon  the  nature  and  extent  of  the  inflammatory  condition.  If  the 
conjunctiva  alone  is  involved,  it  may  be  sufficient  to  cleanse  the  eye  fre- 
quently with  a  proper  lotion  consisting  of  normal  salt  solution  or  a  solu- 
tion of  one  grain  of  sulphate  of  zinc  to  the  ounce  of  camphor  water,  and 
the  use  of  a  shield  to  protect  the  eye  from  the  light.  If  the  deeper  struc- 
tures of  the  eye  are  attacked,  involving  the  distention  of  the  anterior 
chamber,  the  latter  may  require  tapping.  When  the  iris  is  involved, 
instillation  of  a  solution  of  atropine  should  be  used  daily  to  keep  the 
pupil  dilated.  In  more  severe  attacks,  when  the  inflammation  becomes 
intense,  a  leech  may  be  applied  to  the  temple  or  a  blister  behind  the 
ear.  Anodynes  should  be  administered  in  proper  quantity.  In  chronic 
cases  the  condition  of  the  patient  generally  calls  for  the  use  of  tonics, 
change  of  air,  and  a  nutritious  diet,  which  course  should  be  rigorously 
adopted  for  obvious  reasons. 

GONORRHCEAL    OPHTHALMIA. 

This  virulent  inflammation  is  always  due  to  the  direct  transference  of 
gonorrhoeal  pus  from  the  diseased  urethra  to  the  eye,  perhaps  the 
patient's  own  eye,  perhaps  the  eye  of  another,  It  also  attacks  the  eyes 
of  infants,  having  been  acquired  during  birth  from  gonorrhoeal  pus  in 
the  vagina. 

In  most  instances  this  affection  is  the  result  of  carelessness  on  the  part 
of  the  patient,  who  failing  to  exercise  proper  precautions  in  cleansing  the 
hands  after  handling  the  genitals,  either  in  a  moment  of  thoughtlessness 
or  during  sleep,  infects  one  or  both  eyes  by  the  contact  of  the  ringers. 
The  surgeon  is  guilty  of  contributory  negligence  who  does  not  impress 
upon  the  patient  the  danger  of  contamination  and  the  importance  of  ab- 
solute cleanliness  of  the  hands  after  handling  the  penis  infected  with 
gonorrhoea.  The  gonococci  are  the  causative  factors  of  this  virulent  in- 
flammation. There  is  said  to  exist  a  milder  affection  caused  by  inocula- 
tion with  some  of  the  pyogenic  microbes  obtained  from  vaginal  or  urethral 
discharges  which  are  not  gonorrhoeal. 

Fortunately,  gonorrhoeal  ophthalmia  is  rare,  doubtless  due  to  the  fact 
that  the  danger  to  the  eye  of  contact  with  gonorrhoeal  pus  is  quite  gener- 


GONORRHCEAL  OPHTHALMIA.  161 

ally  understood.  The  disease  is  not  often  double  at  the  start,  but  it  is 
very  apt  to  become  so  during  its  course,  unless  great  care  be  taken  to 
shield  the  well  eye  while  the  other  is  being  treated. 

Symptoms. — Within  a  few  hours  after  contagion  the  eye  feels  dry  and 
itching,  as  if  sand  were  beneath  the  lids.  The  eye  waters  a  little  from 
the  start,  and  the  conjunctiva  promptly  becomes  red,  the  lids  slightly 
oedematous. 

The  pain,  swelling,  and  discharge  increase  with  alarming  rapidity. 
The  upper  lid  swells  so  much  and  so  rapidly  that  it  soon  completely 
covers  the  lower  lid,  and  lies  out  prominently  upon  the  cheek,  red  and 
oedematous. 

The  conjunctiva  beneath  is  the  seat  of  oedematous  swelling.  It  be- 
comes highly  vascular,  looking  raw,  sometimes  livid  in  color,  raised  into 
a  thick  border  around  the  cornea  (chemosis),  which  lies  at  the  bottom  of 
the  cavity  formed  by  the  swollen  conjunctiva,  generally  bathed  in  pus. 

The  pus,  green  and  thick,  flows  out  abundantly  upon  the  cheek,  thinned 
from  time  to  time  by  a  gush  of  tears,  sometimes  tinged  with  blood.  The 
lids  partly  stick  together  with  the  thick  incrustations  of  matter  which 
incessantly  flow  away.  The  epithelium  upon  the  cheek  becomes  sodden 
and  perhaps  excoriated  with  the  acrid  secretions. 

The  cornea  soon  gets  into  difficulty  from  strangulation  by  the  chemo- 
sis. It  becomes  at  first  infiltrated,  then  softened  at  the  edge  at  points 
underlying  the  swollen  conjunctiva,  and  so  rapidly  do  the  morbid  changes 
occur  that  within  twent}r-four  hours  from  the  commencement  of  the  affec- 
tion the  cornea  may  have  ulcerated  to  the  point  of  perforation.  Abscess 
may  form  in  the  cornea  and  discharge  externally,  followed  shortly  by  a 
giving  way  in  the  posterior  wall  of  the  abscess,  which  allows  the  fluid  to 
escape  from  the  anterior  chamber  and  the  iris  to  protrude  at  the  opening. 
Again,  the  whole  cornea  may  ulcerate  peripherally  and  drop  out  like  a 
watch-glass,  and  this  may  be  followed  by  an  escape  of  the  crystalline  lens 
and  suppuration,  with  destruction  of  the  entire  contents  of  the  globe. 

Meantime,  pain  is  often  most  intense  and  photophobia  extreme.  The 
pain  is  felt  not  only  in  the  eye  but  all  around  it.  There  may  be  little  or 
no  fever  (unless  the  globe  suppurates),  but  profound  depression  is  the  rule. 
A  sense  of  some  impending  catastrophe  seems  to  overwhelm  the  sufferer. 

The  diagnosis  and  prognosis  of  gonorrhoeal  ophthalmia  depend  upon 
the  presence  or  absence  of  the  gonococci  in  the  discharge  from  the  eye. 
Other  forms  of  virulent  ophthalmia  may  be  so  intense  as  to  simulate 
strongly  the  gonorrhoaal  form.  The  microscope  will  settle  the  question 
beyond  doubt  and  should  always  be  resorted  to  at  the  onset  of  the  malady, 
as  the  prognosis  of  gonorrhoeal  ophthalmia  always  depends  upon  its  early 
recognition  and  prompt  and  vigorous  treatment. 

The  less  virulent  form,  not  due  to  gonococci,  is  not  a  grave  disorder, 
and  much  less  likely  to  lead  to  the  serious  consequences  which  are  so  sure 
11 


162  VENEREAL  DISEASES. 

to  follow  rapidly  in  the  wake  of  an  untreated  attack  of  true  gonorrhoeal 
ophthalmia.  In  thi3  latter  case  the  prognosis  given  should  always  be  a 
grave  one.  When  active  treatment  is  established  at  the  onset  of  the 
inflammation  the  chances  of  recovery  are  good,  while  the  restoration  of 
the  sight  in  one  or  both  eyes  is  exceedingly  doubtful  after  ulceration  of 
the  cornea  has  occurred.  Incomplete  destruction  of  the  structure  of  the 
eye  may  leave  the  eyesight  only  partially  impaired,  and  deformities  may 
remain  which  are  amenable  to  operative  treatment. 

Treatment.— When  one  eye  is  found  to  be  the  seat  of  contagious  puru- 
lent ophthalmia,  it  becomes  the  physician's  duty  immediately  to  protect 
the  other  eye. 

The  curative  treatment  of  purulent  contagious  conjunctivitis  rests 
upon  cleanliness,  relief  of  strangulation,  and  arrest  of  suppuration. 

Cleanliness  must  be  maintained  through  the  whole  course  of  the  affec- 
tion. Frequent  application  of  cold  compresses  is  to  be  practised,  and 
the  discharge  continually  washed  away  with  saturated  boric-acid  solution 
or  corrosive  sublimate,  1 : 10,000.  These  washings  may  be  repeated,  with 
advantage  hourly,  or  at  such  intervals  as  may  be  called  for  by  the  accu- 
mulation of  pus.  Anything  that  touches  pus  from  the  eye  should  be 
burned  and  the  nurse  cautioned  to  preserve  her  own  eyes  against  contagion, 
preferably  by  wearing  protective  spectacles. 

Thin  compresses,  soaked  in  iced  water  and  constantly  changed,  should 
be  applied  to  the  eye.  A  night  nurse,  as  well  as  a  day  nurse,  is  called 
for  to  perform  this  arduous  task.  The  constant  application  of  cold  to  the 
eye  is  of  great  importance,  and  the  means  which  can  effect  this  most 
continuously  should  be  employed.  Small  quantities  of  pounded  ice,  tied 
in  a  piece  of  rubber  tissue,  serve  well  in  most  cases,  but  after  the  vitality 
of  the  cornea  is  threatened  and  ulceration  has  commenced,  it  is  well  to 
be  prudent  in  the  use  of  ice  or  to  suspend  it  altogether. 

Among  the  local  applications  used  with  the  view  of  keeping  down 
pus  formation,  the  nitrate  of  silver  in  solution  holds  the  first  rank.  It 
is  of  value  when  the  pus  begins  to  be  freely  formed,  and  the  strength  of 
solution  employed,  as  well  as  the  frequency  of  the  applications,  is  decided 
by  the  ^iolence  of  the  flow  of  pus  and  by  the  effect  of  the  applications 
upon  it.  It  is  best  to  use  the  nitrate  of  silver  in  solution,  on  account  of 
the  difficulty  of  touching  all  parts  of  the  inflamed  conjunctiva  with  the 
solid  stick.  It  is  well  to  employ  two  solutions .  one  quite  mild,  from 
three  to  six  grains  to  an  ounce  of  water,  to  be  applied  every  two  or 
three  hours ;  and  another,  much  stronger,  from  ten  grains  up  to  a  drachm 
in  an  ounce  of  water,  to  be  applied  at  intervals  when  the  secretion  of  pus 
becomes  too  considerable  to  be  held  at  all  in  check  by  the  milder  solution. 
The  strength  of  the  caustic  solution  of  course  must  be  regulated  by  its 
effect  upon  the  pus-forming  process.  If  a  reasonably  mild  solution  will 
hold  it  in  check,  so  much  the  better;  if  not,  recourse  may  be  had  at  each 


GONORRHCEAL,   OPHTHALMIA.  163 

application,  after  an  interval  of  eight  to  twelve  hours,  or  longer  if  the 
solution  is  quite  strong,  to  a  solution  of  greater  strength,  until  the  de- 
sired effect  has  been  attained,  after  which  the  intervals  between  the 
applications  may  be  lengthened  or  their  strength  diminished. 

In  making  applications  of  the  nitrate  of  silver  to  the  conjunctiva,  the 
lids  should  be  everted  as  much  as  possible,  and  the  application  made  in 
the  main  upon  the  palpebral  conjunctiva;  that  upon  the  globe  is  of  less 
importance,  and  every  effort  should  be  made  to  avoid  getting  any  of  the 
solution  upon  the  cornea  already  devitalized  by  the  strangulation  of  the 
vessels  supplying  its  nourishment,  and  especially  since  it  may  permanently 
discolor  the  cornea.  The  conjunctival  culs-de-sao  stand  in  especial  need 
of  the  applications,  which  can  hardly  be  made  too  thoroughly  at  these 
points.  After  each  application  of  the  nitrate  of  silver  the  eye  should  be 
freely  brushed  over  with  a  strong  salt  solution  to  neutralize  all  excess 
of  the  nitrate  of  silver  which  may  remain  in  the  eye.  Cold  compresses 
upon  the  eye  after  each  application  of  caustic  will  help  to  allay  the  pain. 

When  the  conjunctiva  and  lids  swell  much,  the  eye  suffers  from  ten- 
sion in  two  ways :  by  the  tightness  of  the  tarsal  border  which  irritates 
the  eye  and  prevents  a  free  outflow  of  the  discharges,  and  by  the  chemo- 
sis  of  the  conjunctiva  which  strangulates  the  cornea.  Both  of  these 
strangulations  may  and  should  be  relieved,  the  first  by  freely  cutting 
the  outer  canthus,  enlarging  the  palpebral  slit;  the  second  by  deep  and 
thorough  scarification  of  the  chemosed  conjunctiva. 

The  cornea  requires  especial  attention.  The  cup  at  the  bottom  of 
which  it  lies  should  be  washed  out,  and  the  edge  of  the  cornea  all  around 
under  the  overhanging  chemosed  conjunctiva  should  be  frequently  in- 
spected, to  detect  the  commencement  of  abscess,  or  of  the  ulcerative 
process.  As  soon  as  rupture  of  the  anterior  chamber  seems  imminent, 
the  escape  of  the  fluid  should  be  anticipated  by  paracentesis  of  the  cornea, 
and  the  incision  should  be  kept  fistulous,  if  possible,  by  the  use  of  a  fine 
probe,  until  the  cornea  is  out  of  danger. 

A  solution  of  atropine  should  be  dropped  into  the  eye  several  times 
a  day  from  the  first.  It  tends  to  diminish  intra-ocular  tension,  to  reduce 
pain,  and  to  keep  the  iris  out  of  harm's  way,  either  from  adhesion  or 
from  prolapsing  into  any  fortuitous  opening  in  the  cornea,  dfie  to  the 
perforation  of  an  ulcer.  Should  such  prolapses  occur,  any  portion  which 
projects  may  be  cut  away.  Adhesion  of  the  iris  to  the  cornea  at  the  point 
of  prolapse  is  quite  certain  to  take  place,  calling  perhaps  for  iridectomy 
when  the  patient  recovers. 

As  the  eye  begins  to  recover,  it  must  be  shaded  from  the  light  and 
tenderly  nursed  for  a  long  time.  The  lotions  of  nitrate  of  silver  may  be 
gradually  reduced  in  strength,  and  finally  substituted  by  mild  solutions 
of  sulphate  of  zinc,  or  alum,  or  by  normal  salt  solution.  An  eye  may 
come  out  of  the  contest  much  damaged,  but  yet  capable  of  being  nursed 


164  VENEREAL  DISEASES. 

up  to  the  point  of  being  of  considerable  use  to  its  possessor.     In  bad 
cases  vision  is  totally  destroyed. 

The  internal  treatment  should  be  supporting  and  tonic  throughout, 
all  the  energy  of  the  treatment  being  devoted  to  the  local  measures. 
Mercury,  up  to  the  point  of  producing  salivation,  has  been  advised  in  bad 
cases  in  which  there  is  a  diphtheritic  tendency,  but  the  suggestion  by  no 
means  receives  the  uniform  indorsement  of  authorities,  and  is  of  ques- 
tionable propriety,  certainly  so  far  as  regards  a  majority  of  the  cases 
seen  in  cities  where  the  vitality  of  the  individual  is  not  high.  The 
malady  itself  is  unquestionably  very  debilitating,  and  tonics  and  good 
food  are  called  for  more  than  any  other  internal  remedies.  Laxatives 
are  usually  required,  with  a  judicious  use  of  anodynes  to  insure  sleep 
and  control  pain. 


PART  II. 

CHANCROID  AND  SYPHILIS. 


CHAPTER  I. 

CHANCROID. 
DEFINITION,  ETIOLOGY,  AND  CLINICAL  HISTORY. 

Definition. — Chancroid  is  a  virulent  ulcer,  purely  local  in  character. 
It  is  always  due  to  inoculation  of  the  surface  with  pus  derived  from  a 
similar  ulcer,  and  its  own  secretions  are  freely  auto-inoculable. 

These  characters  are  cardinal  and  uniform.  Clinically,  a  chancroid 
does  not  exist  which  does  not  fulfil  each  of  these  conditions.  This  state- 
ment applies  to  the  genuine  type  of  this  local  venereal  sore.  The  name 
of  chancroid  is  sanctioned  by  long  usage  and  generally  adopted  in  this 
country.  It  is  otherwise  spoken  of  as  the  "soft  chancre,"  as  distin- 
guished from  the  "  hard  chancre, "  or  primary  syphilitic  lesion.  These 
latter  names  are  to  be  discouraged  for  general  usage  as  they  imply  dis- 
tinctive characteristics — "  soft "  and  "  hard  " — which  are  not  invariably 
to  be  found  in  all  instances  of  these  two  lesions,  but  on  the  contrary  are 
sometimes  reversed.  The  fact  should  not  be  lost  sight  of,  however,  that 
the  characteristic  of  "  hardness  "  or  induration  generally  belongs  to  the 
structure  of  the  "  syphilitic  chancre, "  and  that  the  existence  of  a  condi- 
tion simulating  it,  in  connection  with  chancroid,  is  exceptional. 

Chancroid  possesses  an  individuality  as  clear  and  distinct  as  either  of 
the  other  venereal  diseases — gonorrhoea  and  syphilis.  The  history  is  not 
so  ancient  which  relates  how  it  successfully  passed  through  one  era  of 
obscurity,  during  which  it  was  attempted  to  merge  the  two  distinct  dis- 
eases, chancroid  and  syphilis,  into  one  family.  This  one  time  vexed 
question  has  been  settled  beyond  all  doubt  or  cavil.  No  possible  relation 
exists  between  these  two  maladies,  as  was  demonstrated  by  the  energetic 
campaign  inaugurated  by  Ricord  and  culminated  by  Bassereau. 

An  attempt  to  trace  the  history  of  chancroid  has  given  occasion  for 
the  display  of  much  erudition.  No  author  has  been  more  painstaking  hi 
this  direction  than  Bassereau, '  who  brings  out  evidence  from  the  writings 
of  ancient  Greek,  Latin,  and  Arabian  surgeons  which  establishes  the 
presumption  that  contagious  venereal  ulcers  have  existed  from  all  time ; 
and  that  some  at  least  of  these  ulcers  were  chaucroidal,  it  is  hardly  rea- 
sonable to  doubt. 

Description. — A  typical   chancroid,  unirritated  and  uncomplicated,  is 

'"Traite  des  Affections  de  la  Peau  symptomatiques  de  la  Syphilis,"  Paris, 
1852,  p.  217  et  seq. 


jgg  VENEREAL  DISEASES. 

a  rounded  ulcer.  In  a  furrow  it  is  oval,  large  or  small,  single  or  multi- 
ple, simple  or  composed  of  several  ulcers  which  have  run  together.  A 
faint  pink  areola  surrounds  its  edges  which  are  abrupt,  sharply  cut  at 
right  angles  to  the  surface  (not  sloping  away),  and  very  often  under- 
mined, because  the  superficial  integument  resists  the  advance  of  the 
spreading  ulcer  a  little  longer  than  the  less  dense  underlying  structures. 
The  bottom  of  the  ulcer  is  either  pallid,  with  pink  granulations,  bathed 
in  thick  pus,  or,  more  often,  pultaceous,  yellow,  looking  like  dirty  cream ; 
and  this  surface,  composed  of  sloughy  structures,  permeated  with  pus,  is 
adherent,  and  blood  flows  on  any  attempt  at  its  removal.  The  base  of 
the  ulcer  can  be  easily  lifted  up  from  the  tissues  beneath,  and,  although 
consisting  of  an  inflammatory  oedema,  when  rolled  between  the  thumb  and 
finger  presents  no  marked  rigidity. 

The  pus  is  creamy  and  freely  secreted  from  the  ulcerated  surface,  and 
contains  the  broken-down  detritus  of  the  anatomical  elements  which  have 
been  involved  in  the  progressive  march  of  the  destructive  ulcer.  There 
may  be  no  pain  associated  with  it  except  from  handling  or  friction,  or 
during  erection. 

Such  is  the  simple  clinical  chancroid  as  seen  in  a  typical  case.  Com- 
plications, however,  may  attend  it  and  subject  its  appearance  to  varia- 
tions. The  more  it  differs  from  this  type,  the  less  possible  is  it  for  the 
surgeon  to  be  positive  in  his  diagnosis. 

It  is  therefore  of  the  first  importance,  in  the  study  of  venereal  dis- 
ease, to  comprehend  what  a  chancroid  is  and  to  what  variations  it  is 
liable,  especially  in  these  modern  days  when  every  ulcer  produced  by 
inoculation  finds  some  sturdy  advocate  ready  to  proclaim  it  a  chancroid. 

Varieties. — The  typical  chancroid,  as  described  above,  is  generally 
superficial  and  round,  or  may  be  unsymmetrically  irregular  on  account 
of  the  situation,  or  the  shape  of  the  abrasion  or  fissure  inoculated,  or  on 
account  of  the  running  together  of  several  chancroids  of  different  sizes, 
in  which  case  its  border  is  irregular  and  uneven.  This  is  the  exulcerous 
lesion.  Multiple  chancroid  of  the  anus  is  stellate. 

Instead  of  being  an  open  ulcer,  chancroid  sometimes  remains  scabbed 
over.  The  thick  pus  dries  up  on  the  surface,  but  continues  to  be  formed 
beneath  the  scab,  from  the  sides  of  which  it  oozes  under  pressure.  It 
advances  by  the  formation  of  new  rings  of  pus  under  the  epidermis 
around  the  old  scab,  and  generally  has  a  livid  areola  outside  of  all.  It 
is  by  no  means  common,  is  called  ecthymatous  chancroid,  and  is  more  apt 
to  be  found  on  the  integument.  Lift  off  the  crust  in  such  a  case  and  the 
characteristic  ulcer  will  be  revealed. 

In  follicular  chancroid,  infection  takes  place  through  the  mouth  of  a 
healthy  follicle.  It  is  a  clinical  sore,  and  cannot  be  produced  artificially. 
Inoculation  takes  place  beneath  the  plane  of  the  surface,  and  if  the 
latter  happens  to  be  tough  it  retains  its  integrity  for  a  considerable 


ETIOLOGY   OF   CHANCROID.  169 

period.  When  first  seen  it  is  a  large  acuminated  pustule  which  varies  in 
size,  and  is  full  of  thick  pus.  Suppuration  tends  to  spread  peripherally 
beneath  the  epidermis  until  the  latter  has  broken  or  is  cut  away,  when  the 
typical  chancroid  is  disclosed.  The  incubation  period  of  follicular  chan- 
croid is  naturally  long. 

The  base  of  an  unirritated  chancroid  is  soft.  If  inflamed  from  irrita- 
tion, it  becomes  hard,  indurated,  and  elevated  above  the  surrounding 
plane.  In  this  form  it  is  spoken  of  as  the  ulcus  elevatum.  This  indura- 
tion sometimes  cannot  be  distinguished  with  certainty  from  the  induration 
of  syphilitic  chancre.  Generally,  however,  the  difference  is  striking. 
The  induration  of  chancroid  is  manifestly  an  inflammatory  affair.  The 
integument  is  discolored  for  a  certain  distance  around  the  edge  of  the  ulcer, 
with  a  distinct  inflammatory  blush.  The  edge  of  the  induration  is  not 
sharply  defined,  but  fades  away  insensibly  into  the  surrounding  tissues. 
Pressure  upon  the  induration  causes  pain.  The  typical  induration  of  a 
syphilitic  chancre  is  a  tense,  elastic,  insensitive,  non-adherent,  sharply 
defined  underlying  induration  so  familiar  to  the  fingers  once  accustomed 
to  it,  and  yet  so  difficult  to  be  certain  about  in  all  cases  in  which  it  is  im- 
perfectly developed.  The  induration  of  syphilitic  chancre  often  precedes 
the  ulcer,  or  occurs  simultaneously  with  it.  That  of  chancroid  always 
follows  the  ulcer. 

When  the  inflammation  of  chancroid  is  intense  and  rapidly  attacks  the 
surrounding  structure,  causing  sloughing  or  gangrene  of  the  tissues,  it  is 
called  phagedenic  chancroid ;  and  when  it  becomes  more  or  less  chronic, 
is  continuously  progressive  and  irregular  in  its  course,  sometimes  healing 
in  one  portion  while  it  extends  to  another,  it  is  called  serpiginous. 

Pathological  Histology. — The  minute  structure  of  chancroid,  as  re- 
vealed by  the  microscope,  presents  nothing  peculiar.  The  tissues  of  the 
cutis  and  of  the  epidermis  are  swollen,  the  adventitia  of  the  blood-ves- 
sels is  dense,  and  the  walls  of  the  capillaries  are  thickened.  The  area  in- 
volved by  the  ulcer  is  infiltrated  with  round  cells  crowded  together  in 
the  meshes  formed  by  separation  of  bundles  of  connective  tissue.  This 
infiltrate  extends  into  the  tissues  beyond,  involving  the  neighboring 
papillae.  The  ulcer  rests  upon  a  bed  of  inflammatory  oedema,  its  floor 
is  unevenly  dented  with  rounded  or  rugose  granulations  and  covered  with 
a  membranous  pellicle.  Like  the  blood-vessels  the  lymphatics  are  in- 
creased in  number,  and  their  openings  present  upon  the  surface  of  the 
ulcer. 

Etiology. — The  true  nature  of  the  poison  of  chancroid  has  not  been 
revealed.  Different  observers  have  endeavored  to  discover  the  specific 
micro-organism  which  is  the  essential  cause  of  chancroid,  but  no  con- 
vincing demonstration  has  yet  been  given  of  its  discovery,  and  the  pro- 
fession to-day  is  as  ignorant  upon  this  subject  as  it  is  also  of  the  specific 
microbe  of  syphilis.  There  is  a  growing  tendency  to  disclaim  the  exist- 


VENEREAL   DISEASES. 

ence  of  a  distinctive  poisonous  quality  in  chancroidal  pus.  R.  W. 
Taylor,1  of  New  York,  in  conjunction  with  his  late  colleague,  Dr.  Bum- 
stead,  who  years  ago  read  an  able  paper''  before  the  International  Medi- 
cal Congress  on  this  subject,  and  several  other  well-known  authors,  have 
advanced  the  doctrine  that  the  inoculation  of  the  products  of  simple 
inflammation  may  produce  chancroids  notably  upon  persons  who  are 
syphilitic  or  much  debilitated. 

But  why  an  ulcer,  let  it  resemble  a  chancroid  perfectly — produced 
upon  a  person  in  a  healthy  or  debilitated  condition  by  the  inoculation  of 
indifferent  inflammatory  pus — should  be  called  a  chancroid,  even  although 
the  pus  be  repeatedly  auto-inoculable,  is  difficult  to  understand.  The 
auto-inoculability  in  generations  of  pus  simply  confirms  the  well-known 
fact  that  all  pus  is  more  or  less  septic. 

If  chancroid  could  be  produced  de  novo  by  the  inoculation  of  ordinary 
pus,  the  number  of  chancroids  clinically  observed  upon  respectable  people, 
and  those  syphilitic,  cachectic,  or  otherwise,  would  be  vastly  greater  than 
it  is. 

Those  who  dissent  from  the  opinion  that  the  chancroidal  ulcer  is  not 
caused  by  a  specific  virus  do  so  on  the  ground  that  inoculation  with  pus 
containing  ordinary  micro-organisms  may  produce  a  sore  indistinguishable 
from  chancroid,  and  one  which  is  auto-inoculable ;  that  the  common  pyo- 
geuic  microbes  are  always  found  in  chancroidal  ulceration,  and  that  the 
existence  of  a  special  organism  has  never  been  satisfactorily  demonstrated. 
On  the  other  hand,  it  may  be  stated  that  chancroid  has  distinctive  quali- 
ties which  cannot  be  explained  by  the  "  peculiarities  "  of  the  tissues  upon 
which  it  is  found.  It  is  always  highly  contagious,  much  more  virulent, 
and  its  pus  more  freely  inoculable  than  that  of  other  ulcerations.  So 
great  is  its  virulence,  it  has  been  found,  that  even  after  considerable  dilu- 
tion its  contagious  element  remains.  Puche  with  a  drop  of  chancroidal  pus 
diluted  in  a  half  glass  of  water  has  produced  a  typical  chancroidal  ulcer. 

The  existence  of  specific  urethritis  can  hardly  be  denied  on  the  ground 
that  there  exists  a  non-specific  inflammation  closely  resembling  it,  yet  this 
ground  is  taken  to  deny  the  existence  of  a  specific  element  in  chancroid. 
While  the  ordinary  pus  organisms  may  be  found  in  every  instance  of 
chancroidal  sore,  some  observers  claim  to  have  found  in  addition  in  all 
cases  examined  by  them  a  distinctive  microbe.  The  failure  to  produce 
conclusive  testimony  regarding  the  specific  nature  of  such  a  micro-organ- 
ism might  well  be  due  to  the  lack  of  the  suitable  culture  medium.  It 
was  for  a  long  time  impossible  to  obtain  a  pure  culture  of  the  gonococcus 
on  this  account,  and  it  is  only  of  recent  years  that  it  has  been  satisfac- 
torily accomplished.  Finally,  when  the  chancroid  is  thoroughly  cauter- 

"  Venereal  Diseases,"  Lea  Brothers,  1895. 
9  Transactions  of  the  International  Medical  Congress,  1876. 


ETIOLOGY   OF   CHANCROID.  171 

ized  early  enough  in  its  life  to  include  in  the  slough  all  of  the  infected 
tissue,  a  healthy  granulating  sore  is  left,  which  ceases  to  be  destructive 
and  loses  its  intensely  inoculable  quality. 

Various  writers  hold  opposite  views  on  this  subject.  Taylor  in  this 
country  stands  in  strong  opposition  to  the  belief  that  a  special  microbe 
is  responsible  for  the  existence  of  chancroid,  and  holds  that  it  is  due  to 
the  ordinary  pus  organisms  found  in  all  suppuration.  Finger,  of  Ger- 
many, is  apparently  in  accord  with  the  views  of  Taylor.  Martin,1  of 
Philadelphia,  writing  upon  chancroid  in  1893,  stated  that  the  question 
was  still  subjudice,  but  that  ultimately  the  specific  microbe  would  be 
found.  A  later  work,  in  which  he  is  an  associate  author,  at  the  opening 
of  this  subject  states:  "It  is  generally  accepted  that  chancroid  is  a 
simple  ulcer  caused  by  the  inoculation  of  the  well-known  pyogenic  mi- 
crobes," and  further  along  that  the  question  is  "still  in  doubt." 

The  early  writings  of  Fournier,  Keyes,2  and  others  record  their  be- 
lief, as  a  result  of  exhaustive  study  on  the  subject,  that  chancroid  is  a 
distinctly  unique  local  venereal  sore  due  to  a  specific  poison,  and  at  the 
present  time  these  authors,  while  accepting  the  premises  adduced  by  op- 
ponent thinkers,  that  pus  obtained  from  simple  ulcerations  and  pustules 
is  often  freely  inoculable,  have  not  found  sufficient  reason  to  alter  their 
views. 

A  number  of  serious  workers  and  scientific  investigators  express  their 
convictions  on  the  subject  more  definitely  in  describing  an  organism  which 
they  have  isolated  and  studied,  and  believe  to  be  the  specific  microbe 
of  chancroid.  One  of  the  earliest  of  these,  Ducrey, 3  describes  an  organ- 
ism found  by  him  constantly  in  the  discharge  of  chancroid,  which  was 
also  found  by  Unna4  in  the  lymph  spaces.  Other  workers  on  the  same 
lines  confirm  their  results. 

The  organism  in  question  is  a  streptobacillus,  being  a  rod-shaped 
body  with  rounded  extremities,  which  is  grouped  for  the  most  part  in 
chains.  It  has  never  been  successfully  cultivated,  possibly  for  want  of 
a  suitable  medium,  and  therefore  a  pure  culture  has  not  as  yet  been 
obtained. 

At  the  present  writing  it  must  be  admitted  that  the  evidence  in  favor 
of  this  being  the  specific  micro-organism  of  chancroid  lacks  convincing 
demonstration. 

Inoculability. — The  inoculability  of  true  chancroidal  pus  is  virulent 
and  rapid.  Such  pus  takes  at  once  upon  the  person  bearing  the  sore, 

'Morrow:  "System  of  Gen i to-Urinary  Diseases,"  etc.;  White  and  Martin; 
"  Gen i to-Urinary  and  Venereal  Diseases,"  Philadelphia,  1898 

2  "Venereal  Diseases,"  William  Wood  and  Company,  1880. 

3Comptes  Rendus  du  Congres  Internat,  de  Derm,  et  de  Syph.,  Paris,  1889, 
p.  229. 

4  Monatschrift  fur  prakt.  Dermat,  vol.  xiv.,  1892,  p.  485. 


}72  VENEREAL  DISEASES. 

demonstrating  its  auto-inoculability  in  an  unmistakable  manner.  The 
healthiest  individual  may  be  made  the  subject  of  experiment— an  ex- 
periment always  successful  unless  the  capacity  of  the  tissues  to  respond 
has  been  overcome  by  prolonged  inoculations  as  in  syphilization.  A 
chancroid  is  not  indefinitely  auto-inoculable;  the  capacity  of  the  skin 
to  furnish  ulcers  upon  local  irritation  of  the  proper  sort  Las  its  limit. 
The  early  investigators  were  too  positive  in  their  statements  about  chan- 
croidal  pus.  Truly  it  is  very  virulent.  A  patient  in  high  fever  (typhoid) 
will  take  it;  cancer,  leprosy,  a  previous  chancroid,  none  of  these  prevent 
a  take  if  chancroidal  pus  be  properly  inoculated;  but  the  " syphilizers " 
have  clearly  demonstrated  that  the  skin  may  be  worn  out  in  its  capacity 
of  responding  to  the  repeated  inoculation  of  chancroidal  or  other  pus. 
After  a  period  of  rest  the  skin  will  act  again  upon  inoculation,  and  the 
patient  then  may  be  repeatedly  inoculated  until  again  the  inoculation  will 
no  longer  take.  Syphilization  or  repeated  inoculations  with  pus  pre- 
sumed to  be  syphilitic,  is  a  practice  introduced  at  a  time  when  the  dis- 
tinction between  chancroid  and  chancre  was  not  generally  recognized,  and 
was  employed  in  the  hope  of  preventing  the  development  of  syphilis  by 
producing  an  immunity  of  the  skin  against  the  absorption  of  the  syphilitic 
virus. 

Different  parts  of  the  body  show  a  varying  susceptibility  to  the  inocu- 
lation of  the  chancroidal  virus.  The  thighs  are  more  susceptible  than  is 
the  abdomen,  and  the  face  is  less  so  than  either  one  of  these  other  regions. 

Although  the  chancroid  is  an  auto-inoculable  ulcer,  an  auto-inoculable 
ulcer  is  by  no  means  necessarily  chancroid.  Pus  which  is  not  chancroidal 
may  be  re-inoculated  upon  another  person,  or  may  produce  a  series  of 
auto-inoculable  ulcers  upon  the  same  individual.  A  great  difference  also 
is  found  in  individuals — some  take  easily,  some  with  difficulty,  some  not 
at  all.  Syphilitic  and  cachectic  persons  form  the  best  subjects  for  inocu- 
lation. A  syphilitic  chancre  which  is  irritated  into  suppuration  may 
also  be  auto-inoculable,  producing  a  pustule  or  an  auto-inoculable  ulcer 
(non-syphilitic) .  Here  it  is  evidently  the  pus  which  is  the  inoculating 
agent  and  not  the  secretion  of  the  chancre.  A  syphilitic  chancre  of  pure 
type  does  not  suppurate  at  all,  and  the  inoculation  of  its  serous  discharge 
does  not  produce  an  auto-inoculable  ulcer.  There  is  nothing  strange  in 
the  fact  that  chancres  irritated  into  suppuration  become  auto-inoculable 
since  the  pus  of  scabies  and  the  pus  of  ecthyma  have  the  same  effect. 

Then,  again,  the  discharge  of  an  inflamed  syphilitic  chancre  by 
"  hetero-inoculation  "  upon  a  healthy  subject  may  produce  nothing,  or  a 
simple  ulceration  or  pustule  in  the  same  manner  as  above. 

These  facts  are  adduced  as  arguments  against  the  claim  that  chancroid 
is  dependent  upon  a  specific  virus,  but  they  illustrate  only  the  generally 
accepted  teaching  in  regard  to  all  pus.  It  has  been  demonstrated  that 
chancroid  may  be  transmitted  by  inoculation  to  the  lower  animals,  and 


ETIOLOGY   OF   CHANCROID.  173 

that  the  poison  which  develops  there  may  be  carried  back  again  and  suc- 
cessfully inoculated  in  man. 

As  in  the  human  subject,  repeated  auto-inoculation  in  animals  soon 
results  in  a  temporary  immunity  against  reproduction  of  the  ulcer. 

Relative  Frequency. — Statistics  drawn  from  hospital  and  dispensary 
experience  show  that  among  the  class  of  patients  who  frequent  these 
institutions  the  frequency  of  chancroid  is  far  greater  than  that  of  syphi- 
litic chancre.  In  private  practice,  however,  this  order  of  the  frequency 
of  chancre  and  chancroid  is  reversed.  Herpetic  troubles  are  certainly 
more  common  on  the  whole  than  either  chancre  or  chancroid,  and  are 
frequently  mistaken  for  the  latter. 

The  conclusion  is,  as  Fournier  has  pointed  out,  that  the  greater  care 
and  neatness  exercised  by  the  higher  classes  protect  them  in  a  measure 
from  chancroid,  but  offer  no  guaranty  against  infection  by  the  seemingly 
less  formidable  primary  lesion  of  true  syphilis.  This  conclusion  becomes 
especially  obvious  on  considering  the  fact  that  mucous  patches,  which 
may  lie  concealed  high  up  in  the  vagina  and  last  for  months  at  a  time, 
are  as  capable  of  communicating  syphilis  as  is  the  true  syphilitic  chancre. 

Manner  of  Contagion. — Chancroids  develop  only  from  contact  of  chan- 
croidal  pus  with  a  surface  deprived  of  epithelium. 

There  are  two  exceptions  to  this  rule,  one  in  which  chancroidal  pus  is 
placed  upon  a  healthy  surface,  remains  there  undisturbed,  erodes  the 
epithelium  by  virtue  of  its  acridity,  and  thus  prepares  a  way  for  the 
absorption  of  the  virus,  and  the  other  in  which  a  little  chancroidal  pus 
gets  into  the  mouth  of  a  healthy  follicle  (see  Follicular  Chancroid) .  The 
period  of  incubation  in  both  cases  is  unusually  long. 

The  methods  of  contagion  are  two,  direct  and  mediate. 

In  direct  contagion  the  source  supplying  the  pus  and  the  part  inocu- 
lated come  into  direct  contact.  This  is  the  usual  way.  In  sexual  inter- 
course, when  a  chancroid  upon  an  individual  inoculates  a  portion  of  over- 
lying contiguous  integument,  when  a  fissure  on  the  physician's  finger 
becomes  contaminated  while  practising  the  vaginal  touch — these  are 
instances  of  direct  contagion. 

Mediate  contagion  means  that  there  is  an  intermediate  carrier  of  the 
pus  which  receives  it  from  its  source  and  deposits  it  where  it  finally  takes 
root.  The  vagina  may  be  the  medium  of  contagion  receiving  the  pus  from 
one  man  to  give  it  up  to  another  immediately  without  itself  becoming 
contaminated,  but  this  must  be  rare.  The  prepuce  may  play  a  similar 
intermediate  part.  The  lancet  of  the  surgeon  gives  rise  to  mediate  con- 
tagion in  cases  of  inoculation. 

The  pus  of  chancroid  remains  virulent  until  the  ulcer  is  healed,  but 
decreases  in  virulence  toward  the  end.  Frozen  and  corked  up  in  bottles, 
the  pus  retains  its  virulence  for  a  long  time  (Boeck).  Boiling  heat, 
acids,  alkalies,  corrosive  sublimate,  alcohol,  decomposition — all  destroy 


174  VENEREAL  DISEASES. 

the  virulence  of  the  pus.  Boeck  believes  that  dried  pus  is  inert;  Sperino 
taught  the  contrary. 

Inoculation  is  spoken  of  under  two  heads — auto-  and  hetero-inoculation. 
Auto-inoculation  is  the  inoculation  of  the  patient  with  the  secretion  of 
the  chancroid  he  himself  bears.  This  may  be  effected  purposely  as  a  test 
by  the  surgeon.  It  may  take  place  by  contact  of  adjacent  surfaces.  In 
such  a  case  it  is  called  spontaneous  auto-inoculation.  Auto-inoculation 
as  a  diagnostic  test  is  not  so  commonly  employed  now  as  it  was  formerly. 
As  a  test  it  is  thought  to  be  deceptive,  since  so  many  other  kinds  of 
pus  produce  ulcers  upon  some  persons.  These  latter  ulcers  are  not  chan- 
croids, but  they  secrete  pus  and  are  apt  to  deceive. 

Yet  auto-inoculation  is  still  an  excellent  resource  in  some  cases,  the 
frank  take  of  the  true  ulcer  being  very  characteristic  and  always  easy  to 
obtain  upon  a  fresh  subject — a  fact  which  cannot  be  affirmed  to  the  same 
extent  about  any  other  kind  of  pus. 

A  point  suitable  for  auto-inoculation  for  diagnostic  purposes  is  the 
breast  below  the  nipple.  A  true  chancroid  will  undoubtedly  always  take 
here,  but  the  resulting  sore  is  not  apt  to  be  troublesome,  and  phagedsena 
is  almost  unheard  of  in  this  region. 

Hetero-inoculation  is  the  inoculation  of  pus  from  one  patient  to 
another,  as  practised  by  syphilizers.  Chancroid,  as  found  clinically,  is 
also  the  result  of  hetero-inoculation. 

Clinical  History. — Probably,  changes  in  the  tissues  commence  im- 
mediately upon  contact  of  the  virus  with  a  denuded  surface.  By  the 
end  of  twenty-four  hours  the  inoculated  point  is  distinctly  red,  during  the 
second  or  third  day  a  pustule  forms,  and  generally  by  the  third  day,  if 
the  pustule  be  broken,  a  fully  formed  typical  chancroid  is  found,  with  its 
abrupt  margin,  suppurating  floor,  soft  base,  pink  areola,  etc.  When  first 
found  by  the  patient,  it  is  generally  already  an  ulcer  or  an  exulcerated 
fissure.  Sometimes  it  is  a  pustule. 

Clinically  the  incubation  period  of  chancroid  should  be  placed  at  two 
or  three  days,  very  rarely  longer.  It  may  reach  a  week,  possibly  ten 
days  in  cases  of  follicular  chancroid,  or  when  the  pus  has  been  deposited 
upon  unbroken  epithelium  and  has  to  erode  its  way  through  before  it 
can  take  effect.  Sometimes  the  ulcer  is  not  found  by  an  unobservant 
patient  until  many  days  have  elapsed,  because  it  has  caused  no  paia  and 
has  not  attracted  attention. 

Uncomplicated  chancroid  tends  to  run  through  three  definite  periods : 
the  period  of  increase,  the  stationary  period,  the  period  of  repair. 

Period  of  Increase. — This  lasts  one  or  two  weeks,  occasionally  a  little 
longer.  The  ulcer  preserves  its  characteristic  features  as  it  increases  in 
size.  It  generally  stops  when  it  reaches  about  one-fourth  of  an  inch  in 
diameter,  but  may  rapidly  spread  to  the  diameter  of  an  inch  or  more. 

Stationary  Period.—  During  about  two  weeks,   sometimes   longer  if 


CLINICAL  HISTORY   OF  CHANCROID.  175 

unmolested,  the  ulcer  tends  to  remain  stationary,  not  undergoing  any 
change  that  can  be  appreciated.  In  persons  not  very  susceptible  to  the 
poison,  the  stationary  period  does  not  exist,  but  repair  sets  in  after  the 
ulcer  has  reached  a  certain  size. 

Period  of  Repair.  — This  comes  on  gradually.  The  floor  of  the  ulcer 
grows  more  pink  and  even,  the  edges  become  sloping,  and  cicatrization 
advances  slowly  from  the  circumference  toward  the  centre. 

Many  of  the  deviations  in  the  typical  features  of  chancroid  lead  to 
variations  in  its  course. 

Subjective  Symptoms. — An  uninflamed,  uncomplicated  chancroid  is 
not  painful.  If,  however,  it  be  irritated  by  its  position,  or  from  local 
applications  or  other  cause,  then  it  becomes  more  or  less  painful,  accord- 
ing to  the  amount  of  inflammation  accompanying  it.  A  rapidly  spread- 
ing chancroid  is  painful,  as  is  also  a  chancroid  when  attacked  by  gangrene 
or  phagedaena. 

Situation. — Chancroid  is  commonly  found  in  the  furrow  behind  the 
corona  glandis  on  the  penis  of  the  male,  and  posteriorly  in  the  fourchette 
of  the  vagina  of  the  female.  A  natural  pocket  exists  at  these  points,  the 
epithelium  is  soft  there,  and  abrasions  are  not  uncommon,  especially  along 
the  side  of  the  f renum  in  the  male.  In  this  situation  chancroid  frequently 
ulcerates  its  way  beneath  the  frenum,  and  sometimes  perforates  the  ure- 
thra. The  pus  naturally  gravitates  to  the  fourchette  in  the  female. 

No  portion  of  the  body  is  exempt  from  inoculation  by  chancroid.  The 
head  and  face,  once  considered  exempt,  have  been  proved  not  to  be  so  by 
numerous  observers. 

Chancroids  are  common  anywhere  upon  or  within  the  prepuce  in  the 
male,  the  ostium  vaginae  in  the  female.  At  the  orifice  of  the  urethra 
they  are  encountered  in  both  sexes.  Chancroid  deep  in  the  urethra  of 
the  male  is  very  rare.  The  anus  and  rectum  are  the  seat  of  chancroid 
either  communicated  a  preposterd  venere,  or,  in  the  female,  due  to  spon- 
taneous auto-inoculation,  the  chancroidal  pus  trickling  down  over  the 
anus  from  the  vaginal  fourchette  as  the  patient  lies  upon  her  back.  The 
fingers  of  the  surgeon  or  of  the  patient  may  become  poisoned  while 
handling  the  genitals. 

Number. — Chancroid  is  generally  multiple  among  hospital  and  dis- 
pensary patients,  often  solitary  in  the  better  classes,  who  are  more 
scrupulously  clean.  If  multiple  abrasions  have  been  simultaneously 
poisoned  during  sexual  intercourse,  the  resulting  ulcers  will  naturally  be 
multiple  from  the  first.  Often,  however,  but  one  sore  comes  out  at  first, 
and  this  by  spontaneous  auto-inoculation  produces  many  similar  sores  in 
the  immediate  neighborhood.  Around  the  anus,  and  at  the  margin  of  the 
prepuce,  it  is  nearly  always  multiple.  When  chancroid  is  multiple  from 
the  first,  the  numerous  ulcers  are  likely  to  be  small.  Single  chancroid 
is  generally  larger. 


YIQ  VENEREAL   DISEASES. 

Duration. A  typical  ordinary  chancroid  untreated  lasts  in  most  indi- 
viduals from  four  to  eight  weeks,  according  to  its  size.  If  very  small,  it 
is  likely  to  get  well  sooner.  The  larger  it  grows  the  longer  time  does  it 
require  for  cicatrization. 

Irritated  and  inflamed  chancroids  are  slow  in  getting  well.  To  this 
class  belong  all  those  about  natural  orifices  and  where  motion  is  apt  to 
disturb  them,  the  anus,  the  meatus  urinarius,  the  orifice  of  the  pre- 
puce, and  the  back  of  a  knuckle. 

Extensive  chancroids  of  the  vagina  and  rectum  in  the  female,  and  of 
the  rectum  in  the  male,  sometimes  last  indefinitely.  They  cease  iu  the 
end  to  be  true  chancroids,  and  their  pus  ceases  to  be  auto-  or  hetero- 
inoculable.  Their  bases  become  indurated,  they  remain  in  part  cica- 
trized, in  part  ulcerated,  and  frequently  pass  for  tertiary  syphilitic 
ulcerations.  Differential  diagnosis  between  them  and  syphilitic  similar 
lesions  and  some  forms  of  epithelial  cancer  is  sometimes  very  difficult. 
In  the  vagina  excision  is  the  best  treatment.  These  ulcers  are  rarely 
encountered  except  in  the  wards  of  a  large  hospital.  They  are  cus- 
tomarily found  upon  the  persons  of  old  prostitutes. 

The  duration  of  chancroid  is  greatly  influenced  by  phagedaena.  Four- 
nier  has  reported  a  case  lasting  fourteen  years. 

An  uncomplicated  chancroid  occasionally  relapses,  often  without 
obvious  cause.  It  is  possible  for  a  chancroid  which  has  almost  cicatrized 
to  break  down  again  into  ulceration  and  spread  possibly  to  the  same 
extent  as  before,  or  even  farther.  Such  a  relapse  is  generally  due  to 
uncleanliness,  careless  treatment,  sexual  intercourse,  or  abuse  of  stimu- 
lants. 

An  ordinary  uncomplicated  chancroid  may  leave  no  scar.  Generally 
the  scar  is  quite  visible,  especially  when  occurring  upon  the  outer  integu- 
ment, and  when  once  formed  it  is  permanent,  generally  thin  and  smooth, 
not  pigmented,  its  size  and  depth  being  proportionate  to  the  original  sore. 


CHAPTER  II. 

CHANCEOID  (Continued). 
DIAGNOSIS,  PROGNOSIS,  AND  TREATMENT. 

THE  differential  diagnosis  of  chancroid  lies  between  syphilitic  chancre, 
herpes,  balanitis  with  erosions,  ulcerated  fissures  or  abrasions,  mucous 
patch,  ulcerating  gumma,  and  epithelioma. 

Ulcerated  herpes  may  be  mistaken  for  chancroid,  notably  when  it 
appears  as  a  solitary  ulcer.  Herpetic  vesicles  are  rarely  solitary,  and 
when  in  clusters  are  apt  to  run  together.  When  they  ulcerate  they  are 
not  so  deep  as  chancroid  nor  so  destructive.  A  few  days'  observation 
should  determine  the  diagnosis. 

Balanitis  with  erosions  is  not  difficult  to  recognize.  When  exulcera- 
tions  are  present  they  are  not  undermined  and  corrugated,  but  smooth, 
soft,  and  erythematous. 

Syphilitic  chancre  is  described  fully  later  on.  The  following  short 
diagnostic  table  (page  178)  deals  with  the  important  broad  typical  charac- 
ters of  these  lesions.  For  closer  details  of  the  varied  features  of  syphi- 
litic chancre,  the  reader  is  referred  to  the  proper  section. 

An  abrasion  or  fissure  acquired  during  sexual  intercourse  or  otherwise, 
ulcerating  subsequently,  is  sometimes  suggestive  of  chancroid.  The  lapse 
of  a  short  time  under  the  use  of  a  cleansing  lotion  and  dusting  powder 
should  clear  up  the  diagnosis.  The  edges  of  such  an  abrasion  are  gen- 
erally jagged,  and  the  base  of  the  ulcer  is  but  little  depressed  and  dis- 
charges a  thin  sero-pus.  But  yet  such  au  abrasion  by  neglect  in  debilitated 
persons,  by  lack  of  cleanliness,  by  irritating  treatment  (partial  cauteriza- 
tions with  nitrate  of  silver),  may  acquire  in  time  an  appearance  so  nearly 
resembling  that  of  chancroid  that  a  diagnosis  is  almost  impossible.  Under 
these  circumstances  auto-inoculation  may  be  resorted  to  after  the  use  of 
cleanliness  and  local  applications  have  failed  to  cure.  Finally,  if  the 
patient's  state  of  mind  calls  for  it,  no  harm  can  come  by  adopting  the 
conclusion  that  the  suspicious  ulcer  may  be  a  source  of  poison  to  others, 
and  treating  it  as  if  it  were  a  chancroid  by  thorough  destructive  cauteri- 
zation. 

The  diagnosis  between  chancroid  and. a  secondary  syphilitic  ulcera- 
tion  situated  under  the  prepuce  sometimes  gives  trouble.  An  ulcerated 
mucous  patch  rarely  exists  unaccompanied  by  other  lesions,  through  aid 
12 


178 


VENEREAL  DISEASES. 


of  which  its  nature  may  be  defined,  as  well  as  by  its  own  distinctive 
characteristics. 


Syphilitic  Cbancre. 


Cause.— A  specific  virus. . . 


Incubat ion.  —Constant  aver- 
age about  three  weeks. 


Appearance. —Round  or 
oval ;  flat  funnel-shaped, 
or  elevated ;  edges  adher- 
ent and  not  undermined; 
surface  smooth  and  glist- 
ening. 

Secret  ion.— Scant,  serous. . . 

Induration.  —  Generally 
present ;  parchment-like, 
or  cartilaginous  and  ex- 
tensive and  terminating 
abruptly. 

Number.— Single  generally, 
sometimes  multiple. 

Jnoculability. — Not  auto- 
inoculable. 

Course.  —  Slowly  progres- 
sive. 

Duration.  —  Four  to  six 
weeks,  very  slightly 
limited  by  local  treat- 
ment. 

Inguinal  Glands. — Multiple 
enlargements,  separate 
and  freely  movable.  Sel- 
dom suppurate. 


Chancroid. 


A  specific  virus 


None  in  reality ;  clinically 
two  or  three  days,  or 
longer  if  the  virus  be  de- 
posited on  an  unbroken 
surface. 

Round,  oval,  or  irregular; 
ulcerated  excavation; 
edges  abrupt  and  under- 
mined ;  surface  uneven 
and  covered  with  yellow- 
ish membrane 


Herpes. 


Free  and  purulent. 


Absent ;  sometimes  simu- 
lated by  inflammatory 
oedema. 


Irritating  and  acrid  dis- 
charges the  result  of 
uncleanliness  or  inflam- 
mation. 

None. 


Single  round  vesicle  or 
superficial  ulcer ;  clusters 
of  ruptured  vesicles  which 
run  together  and  form 
patches  of  superficial  ul- 
cerations  with  irregularly 
circular  borders. 

Slight  serous  or  sero-puru- 
lent  (it  inflamed^). 

Absent. 


Generally  multiple j  Generally  multiple  but  co- 

alescent. 
Freely  auto-inoculable,  re-  Exceptionally     auto-inocu- 


producing  a  typical  chan- 
croid. 

Rapidly  progressive  and 
destructive. 

Four  to  six  weeks,  materi- 
ally limited  by  caustic 
local  measures. 

Single  enlargement,  peri- 
glandular  swelling,  tis- 
sues boggy,  skin  adhe- 
rent, often  suppurate. 


lable. 
Slowly  progressive. 

Variable ;  limited  by  mild 
local  measures. 


Mild  glandular  swellings ; 
inflammatory  adenitis 
exceptional. 


An  ulcerated  gumma  is  quite  apt  to  appear  under  the  corona  glandis, 
near  the  pocket  of  the  frenum,  late  in  syphilis.  This  ulcer  resembles  a 
chancroid,  and  is  quite  likely  to  eat  into  the  urethra  if  not  arrested  by 
treatment.  Its  underlying  base  and  border  are  quite  hard,  and  its  his- 
tory shows  that  it  started  as  an  induration  under  the  mucous  membrane. 

Certain  chancroids  are  hidden  from  view.  The  urethral  chancroid 
almost  invariably  involves  the  meatus,  but  possibly  might  be  oat  of  sight. 
A  subpreputial  chancroid  in  case  of  phimosis,  an  anal  chancroid  resem- 
bling fissure — these  and  possibly  other  varieties  cannot  be  diagnosticated 
in  the  usual  way.  In  such  case,  when  the  suspicion  of  chancroid  arises, 
the  test  of  auto-inoculation  is  valuable.  If  auto-inoculation  produces  a 
characteristic  chancroid  (especially  if  the  patient  be  not  syphilitic  or 


PROGNOSIS  AND   TREATMENT   OF   CHANCROID.  179 

cachectic),  it  may  be  reasonably  predicated  that  the  source  of  the  inocu- 
lated pus  was  chancroidal. 

Epithelioma  should  not  be  confounded  with,  chancroid  when  carefully 
considered.  It  occurs  as  an  exuberant  new  growth,  in  the  form  of  a 
papillomatous  nodule,  and  not  at  first  as  a  destructive  ulceration. 

In  auto-inoculation  practised  for  purposes  of  diagnosis,  the  following 
facts  should  be  remembered : 

(1)  A  gangrenous  phagedenic  chancroid  loses  its  poisonous  quality, 
just  as  decomposed  chancroidal  pus  is  no  longer  virulent,  and  auto-inocu- 
lation fails. 

(2)  Auto-inoculation  of  almost  any  pus  may  take  and   produce  an 
ulcer  somewhat  resembling  chancroid. 

(3)  An  ulcer  may  be  a  mixed  chancre,  in  which  case  its  auto-inocula- 
tion will  take  as  a  true  chancroid;  but  the  patient  has  syphilis  none  the 
less. 

(4)  Auto-inoculation  of  an  irritated  true  syphilitic  chancre  may  some- 
times take  as  an  ulcer  resembling  chancroid. 

(5)  A  serpiginous  phagedenic  ulcer  is  auto-inoculable,  but  its  auto- 
inoculation  may  produce  a  chancroid  which  in  its  turn  becomes  phage- 
denic, since  phagedaena  is  a  property  of  the  patient  and  not  of  the 
chancroidal  virus  he  secretes. 

Prognosis. — Uncomplicated  chancroid  gets  well  in  a  few  weeks,  and 
never  leads  to  a  result  more  serious  than  a  trifling  local  scar. 

The  fact  that  chancroid  is  not  a  blood  disease  and  never  produces 
syphilis  reduces  all  the  damage  it  can  do  its  bearer  to  such  mischief  as 
any  ulcer  of  similar  extent  and  severity  might  equally  well  accomplish. 
In  rare  instances  this  damage  is  considerable.  A  severe  and  protracted 
chancroid  of  the  rectum  leads  to  stricture  of  that  gut  with  all  its  distress- 
ing results ;  the  mouth  of  the  urethra  may  be  nearly  sealed  up  by  the 
contracting  cicatrix  of  a  chancroid. 

Phimosis  by  cicatricial  contraction,  and  deformity  by  ulceration  into 
the  urethra,  are  possible  results. 

Erysipelas  may  attack  a  simple  chancroid  as  well  as  any  other  lesion. 
The  more  extensive  and  complicated  sores  naturally  lead  to  serious  local 
consequences. 

Phagedaena  may  stretch  itself  over  large  portions  of  the  surface  of  the 
body,  and  last  for  years. 

Sloughing  phagedaena  may  destroy  great  segments  of  the  penis,  or  so 
eat  away  its  outer  investment  that  the  resulting  scar  leaves'  the  organ 
practically  useless.  A  slough  has  been  known  to  open  a  large  vessel,  and 
serious  hemorrhage  as  a  complication  thus  becomes  possible. 

These  extreme  results  are  indeed  possible,  but  they  are  so  rare  that 
they  may  be  disregarded  in  giving  an  ordinary  prognosis. 

Treatment. — The   best  preventive  treatment  against  the  spread  of 


180  VENEREAL  DISEASES. 

ulcers  upon  a  patient  by  spontaneous  auto-inoculation  is  destruction  of 
the  poison  at  its  source,  that  is  to  say,  cauterization  of  the  chancroid,  or 
the  most  absolute  cleanliness  if  total  destruction  be  impossible. 

Chancroid  owes  its  prolonged  existence  to  its  microbic  virulence. 
Destroy  that  virulence  thoroughly  and  the  poisonous  quality  at  once  dis- 
appears, the  ulcer  becomes  a  simple  sore,  and  the  process  of  repair 

begins. 

Unless  a  chancroid  is  very  young,  it  is  apt  to  return  after  being  cau- 
terized. It  is  possible  to  excise  completely  a  chancroid,  including  half 
an  inch  of  surrounding  tissue,  and  even  though  scrupulous  care  has  been 
employed,  it  may  return  at  the  site  of  the  excision.  Some  old  chancroids 
certainly  do  not  get  well  after  the  most  extensive  cauterization.  This  is 
notoriously  true  of  serpiginous  phagedenic  sores,  but  is  not  the  case  with 
recent  chancroid.  Such  an  ulcer  may  be  cauterized  thoroughly  and  lose 
entirely  its  chancroidal  character.  In  an  old  chancroid,  however,  the 
micro-organisms  have  infiltrated  the  tissues  for  a  certain  distance  beyond 
the  base  of  the  ulcer,  and  cauterization  does  not  reach  them.  If  the 
ulcerated  surface  is  destroyed,  it  becomes  reinfected  by  poison  brought 
from  beneath ;  and  for  the  same  reason  when  the  prepuce  is  the  seat  of 
chancroid,  the  wound  of  circumcision  frequently  becomes  poisoned,  in 
spite  of  such  precautions  as  burning  the  chancroid  previously  to  the  abla- 
tion of  the  foreskin  and  perfect  cleanliness  during  and  after  the  operation. 

That  the  poison  in  ordinary  cases  dies  out  after  a  few  weeks  and  is 
eliminated,  while  in  other  cases  of  advancing  phagedsena  it  seems  able  to 
perpetuate  itself  almost  indefinitely,  is  largely  accounted  for  by  unhy- 
gienic conditions,  uncleanliness,  and  alcoholic  excesses.  The  probability 
is  that  the  diligence  is  solely  a  question  of  the  soil  in  which  the  chan- 
croidal poison  finds  itself,  for  phagedaena  is  a  quality  of  the  individual 
and  does  not  imply  the  inoculation  of  any  special  virus. 

With  the  understanding,  then,  that  in  many  old  cases  the  chancroidal 
poison  is  widespread,  and  cannot  be  all  reached  by  any  means  capable  of 
totally  destroying  it,  it  is  the  opinion  among  authorities  that  total  destruc- 
tion of  the  ulcer  is  the  proper  course  to  adopt  in  all  cases  in  which  the  chan- 
croid is  not  of  long  standing.  At  exactly  what  age  chancroid  ceases  to 
be  curable  by  the  destruction  of  its  surface,  and  a  reasonable  amount  of 
tissue  beyond,  cannot  be  stated.  The  rule  is  to  cauterize  a  chancroid 
thoroughly  as  soon  as  its  diagnosis  is  established,  and  to  destroy  all  points 
of  diagnostic  auto-inoculation  very  promptly.  Removal  of  the  sore  by 
curetting  or  complete  excision  is  not  to  be  advised  at  any  period. 

Potential  caustics  are  most  manageable  as  destructive  agents,  and 
therefore  better  than  other  means  of  destruction.  The  chloride  of  zinc 
and  other  pastes  are  less  easy  to  control  than  the  caustic  acids  and  more 
apt  to  produce  prolonged  irritation  of  the  surrounding  tissues.  Pure 
nitric  acid  is  the  best. 


TREATMENT   OF   CHANCROID.  181 

Cocaine  may  be  used  to  allay  pain  caused  by  the  application  of  the 
caustic  acid. 

The  use  of  carbolic  and  nitric  acid  in  combination  is  a  satisfactory 
method.  The  carbolic  intensifies  the  local  effect  of  the  cocaine  and  acts 
as  an  additional  analgesic  against  the  stronger  acid. 

To  prepare  a  chancroid  for  cauterization  the  parts  should  be  first  prop- 
erly cleansed  and  dried.  A  piece  of  absorbent  cotton  moistened  with 
four-per-cent  solution  of  cocaine,  or  a  tablet  triturate  containing  gr.  ss. 
or  gr.  i.  of  the  same,  may  be  placed  upon  the  surface  of  the  ulcer  and  left 
in  contact  about  five  minutes. 

Upon  the  ulcer  so  prepared  a  drop  of  pure  carbolic  acid  is  placed ; 
any  excess  of  acid  that  escapes  should  be  absorbed  with  a  piece  of  blot- 
ting-paper. After  the  lapse  of  a  few  seconds  the  surface  of  the  ulcer  is 
dried,  preferably  with  a  thin  strip  of  blotting-paper.  A  glass  rod,  drawn 
to  a  point,  is  now  dipped  into  fuming  nitric  acid,  and  enough  acid  placed 
upon  the  chancroid  to  fill  its  depression  even  with  the  surface.  Any  ex- 
cess should  be  carefully  soaked  up  with  blotting-paper.  This  application 
is  entirely  painless.  The  surrounding  tissues  are  held  tense,  and  the 
action  of  the  acid  is  watched.  If  the  edges  of  the  ulcer  are  undermined, 
the  point  of  the  glass  rod  should  be  moved  around  under  the  border  be- 
neath the  surface,  so  that  all  the  recesses  of  the  sore  may  be  equally 
acted  upon  by  the  acid. 

As  the  acid  cauterizes  the  base  of  the  ulcer,  an  areola  of  white  color 
is  seen  to  grow  gradually  around  the  sore  under  the  epithelium.  When 
this  areola  gets  to  be  as  broad  as  the  head  of  a  pin,  the  cauterization 
should  be  complete.  If  it  does  not  become  so  broad  after  watching  it  for 
two  or  three  minutes,  the  drop  of  acid  should  be  soaked  out  of  the  ulcer 
and  a  new  one  put  in — and  so  on  until  the  areola  of  white,  dead,  cauterized 
tissue  reaches  the  required  thickness.  The  sore  is  then  dried  and  the 
subsequent  dressing  applied. 

The  eschar  begins  shortly  to  slough  off,  a  line  of  healthy  granulations 
forms  around  and  beneath  it. 

A  small  chancroid  thoroughly  burned  ought  to  be  well  in  ten  days; 
more  extensive  sores  require  more  time. 

The  after-treatment  of  the  cauterized  surface  should  consist  of  the 
application  of  a  moist  dressing,  for  which  purpose  corrosive  sublimate 
solution,  1  :  4,000,  may  be  employed,  keeping  the  parts  thoroughly 
cleansed  and  the  opposing  surfaces  of  the  prepuce  separated  by  the  inter- 
position of  a  piece  of  cotton  or  lint  moistened  with  the  same  solution, 
or  with  1  :  50  carbolic  acid.  A  dry  dressing  may  be  substituted  for 
the  wet  in  the  form  of  a  dusting-powder,  such  as  iodoform  or  one  of 
its  substitutes.  The  smell  of  iodoform  is  a  serious  objection  and  cannot 
be  satisfactorily  disguised.  Nosophen  is  an  iodine  preparation  of  strong 
antiseptic  action,  which  has  proved  of  value.  Eudoxin  is  a  bismuth  salt 


182  VENEREAL  DISEASES. 

of  nosophen  and  possesses  mild  astringent  and  absorbent  properties. 
Other  antiseptic  powders  have  also  been  used,  such,  as  aristol,  europhen, 
acetanilid,  and  iodol. 

It  is  unwise  to  cauterize  a  chancroid  unless  each  and  overy  abrasion 
in  the  neighborhood,  and  all  suppurating  spots,  can  be  totally  and  simul- 
taneously destroyed.  For  if  any  chancroidal  ulceration  remains  it  is  sure 
to  poison  the  healthy  ulcer  left  by  the  separation  of  the  slough,  and  to  re- 
convert it  into  a  chancroid.  Thus,  chancroid  at  the  margin  of  the  prepuce 
cannot  be  cauterized  if  subpreputial  chancroid  also  exists  and  is  spared. 

In  case  of  numerous  subpreputial  chancroids,  if  the  foreskin  be 
naturally  tight  the  reaction  following  cauterization  may  inflame  the  pre- 
puce sufficiently  to  cause  phimosis  and  prevent  retraction  of  the  foreskin. . 
A  fear  of  this  occurrence  need  not  deter  the  surgeon  from  a  use  of  the 
acid.  The  cavity  of  the  prepuce  can  be  kept  syringed  out,  and  if  the 
cauterization  has  been  effective  the  chancroids  will  certainly  get  well, 
even  within  an  inflamed  prepuce. 

When  all  the  chancroids  cannot  be  reached,  or  are  so  large  and  old 
that  cauterization  is  not  advisable,  cleanliness  is  the  first  requisite  of 
treatment.  Frequent  washings  with  sublimate  solution  1 : 2, 000  or  car- 
bolic 1 : 40  are  to  be  recommended.  The  surfaces  should  then  be  treated 
either  with  a  moist  or  dry  dressing,  which  should  be  changed  frequently. 
Unquestionably  an  efficient  local  application  for  such  chancroids  is  iodo- 
forni,  in  powder  or  mixed  into  an  ointment  with  vaseline.  But  respect- 
able people  will  not  use  lodoform.  Its  peculiarly  penetrating  and 
tenacious  odor  is  unmistakable.  Nothing  will  disguise  the  odor  satisfac- 
torily, although  many  expedients  have  been  employed  for  that  purpose. 
Solutions  of  iodoform  in  ether  have  been  recommended.  Their  appli- 
cation is  painful,  the  solvent  evaporates,  and  the  odor  exhales  as  strongly 
from  the  fine  dust  left  precipitated  over  the  surface  of  the  ulcer  as  if  it 
had  been  at  first  deposited  there  in  its  natural  state. 

The  effect  of  iodoform  upon  chancroids  is  often  striking.  It  freshens 
up  the  surface  and  hastens  granulation,  at  which  stage  it  should  be  dis- 
continued. 

Nosophen  also  may  be  employed  as  a  dressing  to  the  chancroids  which 
are  not  treated  by  cauterization  in  the  same  manner  as  iodoform,  after  the 
surface  has  been  thoroughly  cleansed  and  dried.  This  preparation  has 
met  with  decided  favor.  It  contains  a  large  percentage  of  iodine  and  is 
inodorous. 

Glutol  or  formalin  gelatin  is  an  odorless  powder  which  owes  its  anti- 
septic properties  to  the  fact  that  when  decomposed  in  contact  with  a 
wound  surface  it  liberates  formaldehyde  vapor.  Satisfactory  results  are 
reported  from  its  use  in  the  treatment  of  chancroid,  more  particularly 
when  all  sloughing  tissue  has  been  removed  and  when  it  is  desired  to 
assist  cicatrization. 


TREATMENT  OF  CHANCROID  183 

For  the  relief  of  the  pain,  which  sometimes  is  very  acute  with  in- 
flamed chancroids,  powdered  orthoform  may  be  applied  at  odd  intervals 
between  the  other  applications,  and  generally  with  marked  effect. 

When  the  stage  of  activity  of  chancroid  has  passed  and  the  process  of 
repair  seems  to  be  going  on  satisfactorily,  it  is  only  necessary  to  apply  a 
dry  impalpable  absorbent  powder  to  allay  irritation  and  prevent  friction. 
For  this  purpose  may  be  used  equal  parts  of  bismuth,  starch,  and  oxide 
of  zinc,  or  bismuth  and  lycopodium.  If  the  ulcers  prove  sluggish  and 
slow  to  cicatrize  in  the  reparative  stage,  the  application  of  a  solution  of 
nitrate  of  silver,  gr.  x.-xx.  to  the  ounce,  or  of  the  powdered  citrate  of 
silver  (Crede),  may  hasten  their  progress  toward  recovery,  or  a  little 
calomel  and  bismuth,  1 : 10.  Besides  these  there  are  many  soothing  and 
gently  stimulating  applications. 

If  the  sores  are  subpreputial  and  the  prepuce  is  loose,  it  is  well  always 
to  pull  back  the  foreskin  whatever  dressing  is  employed,  and  to  interpose 
a  small  piece  of  gauze  or  absorbent  cotton,  in  such  position  that  it  will  lie 
between  the  sores  and  the  healthy  tissues,  when  the  foreskin  has  been 
replaced. 

When  the  discharge  of  pus  is  considerable,  moist  dressings  are  prefer- 
able, and  lint  slightly  moistened  with  the  fluid  selected  should  be  kept 
constantly  applied  to  the  surface  of  the  ulcer.  One  of  the  following 
lotions  will  serve : 

I£  Hydrargyri  bichlor., gr.  ss.-ij. 

Aquae, 3  iv. 

M. 

B  Acid,  carbolic., 3ij. 

Spts.  rect., 3iij- 

Aquse, I  iv. 

M 

B  Zinc,  sulphocarbolatis, gr  vi. 

Spts  rect., 3  ij- 

Aquae, I  iv. 

M. 

B  Solut  argenti  lactas  (Crede) ,  .        ,        .        .1    2,000 

With  such  moist  or  dry  applications  and  patience,  uncomplicated  chan- 
croids get  well  within  a  reasonable  period. 

Internal  medication  is  of  no  value  in  ordinary  cases.  If  the  patient 
be  manifestly  debilitated,  he  should  receive  tonics  and  good  food,  and  all 
functional  derangements  demand  appropriate  attention,  but  there  is  no 
internal  specific  for  chancroid.  Kest  of  body  is  sometimes  desirable. 

Subpreputial  chancroid  implies  a  chancroid  concealed  by  the  prepuce, 
either  congenitally  tight  so  that  it  cannot  be  retracted,  or  in  a  state  of 
temporary  phimosis  from  inflammation.  The  latter  condition  will  be 
discussed  under  the  head  of  Complications. 


184  VENEREAL   DISEASES. 

When  a  chancroid  is  inside  of  a  congenitally  contracted  foreskin,  its 
presence  can  sometimes  only  be  surmised.  Generally  a  lump,  tender  on 
pressure,  may  be  detected  at  one  spot,  however,  or  there  may  be  several 
of  them ;  and  the  auto-inoculability  of  the  pus,  and  the  possible  existence 
of  chancroids  at  the  margin  of  the  prepuce,  help  to  make  the  diagnosis. 

In  treating  such  chancroids,  if  the  prepuce  be  not  inflamed  and  in 
danger  of  strangulation,  it  is  not  necessary  to  use  the  knife.  No  exten- 
sive destruction  of  the  parts  within  the  prepuce  is  apt  to  occur  unaccom- 
panied by  such  external  evidences  of  destructive  inflammation  as  will 
naturally  call  for  heroic  interference. 

Cleanliness  is  more  necessary  in  treating  these  chancroids  than  any 
others.  A  syringe  with  a  long,  flattened  nozzle  (Fig.  11,  p.  36)  should 
be  used,  its  point  inserted  well  down  to  the  sulcus  behind  the  corona,  and 
into  the  pockets  on  either  side  of  the  frenum.  Warm  injections,  one  of 
the  lotions  given  on  p.  183,  should  be  made  frequently  enough  to  keep 
the  pus  from  accumulating.  lodoform  shaken  up  with  balsam  of  Peru 
may  be  injected  into  the  depths  of  the  preputial  cavity  with  the  prepu- 
tial  syringe.  Generally,  these  chancroids  are  slow,  and  cleanliness,  with, 
time,  are  the  important  elements  in  the  cure. 

Chancroids  of  the  margin  of  the  prepuce,  there  being  no  ulcers  within, 
if  they  can  be  thoroughly  exposed,  should  be  cauterized. 

Chancroids  undermining  the  frenum,  perforating  through  from  one 
side  to  the  other,  call  for  a  division  of  the  frenum,  to  hasten  their  cure 
and  avert  the  possibility  of  bleeding,  should  the  frenum  become  acciden- 
tally ruptured  or  eaten  through  by  ulceration.  This  is  best  accomplished 
by  tying  a  stout  silken  ligature  around  it,  and  cutting  the  ligature  short. 
The  ligature  cuts  its  own  way  through  very  promptly,  and  then  the  open 
chancroid  may  be  treated  more  satisfactorily.  If  chancroid  in  this  region 
is  not  controlled  it  may  give  great  annoyance,  its  destructive  action  ex- 
tending into  the  median  fossa  of  the  glans,  or  perhaps  perforating  the 
urethra,  producing  urinary  fistula. 

Chancroids  at  the  margin  of  the  meatus  urinarius  may  be  cauterized 
unless  they  run  too  far  down  into  the  urethra.  In  the  latter  case  iodo- 
form  plugs  (a  roll  of  lint  covered  with  cerate  and  sprinkled  with  iodoform) 
will  hasten  recovery.  Drethral  chancroids  lower  down  than  the  fossa 
navicularis  are  excessively  rare  and  some  of  the  cases  reported  are  errors 
of  diagnosis. 

Anal  and  rectal  chancroids  are  always  obstinate  and  difficult  to  man- 
age. The  daily  stretching  of  the  parts  by  the  faeces  and  the  difficulty 
of  maintaining  perfect  cleanliness  are  the  main  obstacles  to  recovery. 

Cauterization  is  inappropriate  for  ulcers  in  this  region.  Frequent 
washings  with  warm  water  containing  corrosive  sublimate,  and  confine- 
ment to  bed,  with  lavish  use  of  iodoform  powder  upon  all  the  ulcerated 
surfaces,  is  the  best  treatment  for  recent  chancroids  in  these  regions. 


TREATMENT   OF   CHANCROID.  185 

Constipation  must  be  prevented.  When  the  chancroid  has  lasted  for 
years,  and  produced  stricture  of  the  rectum,  extirpation  with  the  knife 
or  linear  resection  may  be  required. 

Chancroid  of  the  Fingers. — When  the  surgeon  or  accoucheur  gets 
chancroid  upon  the  finger,  it  should  be  thoroughly  cauterized,  and 
dressed  with  one  of  the  moist  or  dry  applications  given  above.  The 
finger  should  be  kept  immovable  upon  a  splint.  A  chancroid  on  a 
knuckle  is  sometimes  as  hard  to  cure  as  a  chancroid  of  the  anus  or  at  the 
meatus  urinarius,  the  reason  being  that  the  incessant  injury  done  by 
motion  of  the  part  keeps  the  ulcer  alive.  An  ordinary  abrasion  will 
sometimes  ulcerate  and  last  for  weeks  upon  a  knuckle,  and  be  mistaken 
for  a  more  serious  condition. 


CHAPTER  III. 

THE  COMPLICATIONS   OF  CHANCROID. 

AN  ulcer  doubtless  cannot  exist  without  some  inflammation,  but  a 
typical  chancroid  is  attended  by  very  little.  Most  chancroids,  however, 
as  encountered  clinically,  are  inflamed  in  a  measure,  and  possess  all  the 
qualities  of  inflammation  to  a  greater  or  less  extent.  This  amount  of 
inflammation  does  not  constitute  a  complication. 

When  a  chancroid  inflames  from  mechanical  or  chemical  irritation,  or 
on  account  of  the  neglect  of  the  patient,  its  base  hardens,  its  discharge 
grows  thinner  and  sanious,  pain  is  complained  of,  and  generally  the 
course  of  the  sore  is  prolonged,  the  surrounding  tissues  becoming  cedema- 
tous  and  indurated,  and  the  ulcer  finally  pale,  flabby,  unhealthy,  going 
on  to  a  slow  cicatrization.  Simple  bubo  is  very  much  more  apt  to  occur 
with  an  inflamed  chancroid  than  with  a  typical  ulcer. 

When  inflammation  complicates  subpreputial  chancroid,  the  tissues  of 
the  prepuce  become  much  engorged,  and  sometimes  very  hard  and  rigid 
from  stiffening  of  the  connective  tissue  by  inflammatory  exudation.  A 
superficial  lymphangitis  is  the  cause  of  these  phenomena;  the  larger 
lymphatic  vessels  may  escape  entirely.  This  lymphangitis  is  not  an 
uncommon  complication  of  chancroid. 

Inflammatory  phimosis  or  paraphimosis,  under  these  circumstances, 
often  ensue.  If  the  chancroid  occupies  the  inner  surface  of  the  prepuce, 
the  latter  is  in  danger  of  strangulation  and  may  undergo  total  gangrene, 
a  large  portion  of  the  prepuce,  with  the  chancroid,  sloughing  away  and 
allowing  the  glans  penis  to  protrude  through  the  opening,  making  a  sort 
of  double-headed  penis.  The  remains  of  the  prepuce  in  such  cases  con- 
tinue thickened  and  indurated,  and  require  to  be  trimmed  away  finally, 
when  cicatrization  is  complete. 

A  more  disastrous  result  of  inflammatory  phimosis  is  the  possibility 
of  many  new  points  of  auto-inoculation  within  the  cavity  of  the  prepuce, 
the  retained  poisonous  pus  excoriating  the  surface  of  the  glaus  penis  and 
perhaps  inoculating  the  meatus.  Portions  of  the  new  chancroids  may 
then  slough,  and  considerable  loss  of  the  glans  penis  ensue,  with  stricture 
of  the  meatus  from  cicatrization.  The  liability  of  causing  bubo  by  allow- 
ing au  inflamed  prepuce  over  a  chancroid  to  remain  long  unrelieved  is  to 
i  borne  in  mind,  and  the  possibility  of  extensive  denudation  of  the  penis 
by  the  backward  burrowing  of  the  retained  chancroidal  pus  has  been 
clinically  proved  (Vidal). 


THE   COMPLICATIONS   OP   CHANCROID.  187 

Inflammatory  paraphimosis  may  complicate  a  chancroid  when  the 
prepuce  is  short.  The  swelling  encircling  the  penis  may  become  so  great 
that  the  circulation  of  that  portion  of  the  penis  lying  in  front  of  the 
constriction  is  menaced. 

The  treatment  of  the  inflammatory  complications  of  chancroid  is  ob- 
vious. Rest  must  be  insisted  upon,  the  penis  elevated  and  covered  with 
moist,  cooling,  evaporating  lotions,  or  with  astringent  solutions.  One  of 
the  following  should  be  kept  constantly  applied  cold  upon  a  thin  cloth  on 
the  outside  of  the  penis : 

3  Glycerini, HI  xx. 

Spts.  rect., 3  i.-ij. 

Liquor,  plumbi  subacetat.  dil.,       .         .  q.s.  ad    §  i. 

M. 
Or— 

Aluminum 'Acetate  Solution. 

1$  Aluminis,       .....  .  gr.  xxx. 

Plumbi  acetat., .3  iiss. 

Aquse,    ......  .    3  vi. 

M.     Filter. 

These  applications  are  palliative.  The  treatment  of  the  chancroid 
meantime  goes  on  by  subpreputial  injections,  iodoform  applications,  or 
whatsoever  it  may  be.  If  the  subpreputial  discharge  of  pus  gains  in 
quantity,  if  the  inflammation  fails  to  yield  and  gangrene  is  to  be  feared, 
then  but  one  course  is  left,  namely,  to  slit  open  the  cavity  of  the  prepuce 
and  dress  with  iodoform  or  nosopheu ;  or,  better  still,  antinosiue,  which 
is  the  sodium  salt  of  nosophen,  and  especially  lauded  for  sluggish  ulcera- 
tions.  This  last  application  is  generally  employed  in  a  five-  to  eight-per- 
cent solution  with  glycerin  or  water.  Cauterization  in  these  cases  will 
not  prevent  the  wound  from  becoming  inoculated  and  only  prolongs  the 
duration  of  the  sore. 

In  cases  of  paraphimosis  the  line  of  stricture  of  the  prepuce  must  be 
divided  with  the  knife  as  soon  as  the  circulation  of  the  penis  in  front  of 
it  is  threatened.  If  the  circulation  continues  perfect  it  is  better  in  most 
cases  not  to  attempt  to  reduce  the  paraphimosis,  since  the  latter  insures 
the  advantage  of  leaving  the  ulcers  exposed  to  view. 

Phagedenic  Chancroid. — This  is  the  most  formidable  of  all  the  local 
complications.  Phagedaena  occurs  in  two  forms :  sloughing  or  gangren- 
ous phagedaena  and  serpiginous.  The  predisposing  general  causes  of 
phagedaena  are  not  uniform.  It  sometimes  attacks  a  florid,  healthy-look- 
ing youth,  and  often  spares  a  cadaverous  consumptive  or  a  patient  debili- 
tated by  excesses  of  all  sorts.  It  is  a  rare  complication.  Phagedsena  is 
not  confined  to  chancroids.  Any  ulcer— syphilitic  or  simple — may  be 
attacked  by  it.  It  is  a  peculiar  quality  of  the  individual.  The  pus  from 
a  phagedenic  ulcer  will  not  produce  phagedsena  by  hetero-inoculation. 


138  VENEREAL  DISEASES. 

This  has  been  abundantly  proved  by  Founder,  Sperino,  Rollet,  and 
others.  Conversely,  it  is  known  that  a  simple  chancroid  produced  upon 
a  patient  with  phagedsena  is  liable  also  to  become  phagedenic,  showing 
clearly  that  the  phagedenic  quality  is  a  personal  one. 

Among  the  presumed  predisposing  causes  of  phagedsena  have  been 
grouped  all  depressing  dietetic,  hygienic,  diathetic,  and  pathological  con- 
ditions— old  age,  misery,  alcoholism,  scrofula,  malaria,  digestive  troubles 

but  not  one  of  these  causes  can  be  proved  sufficient  in  the  majority  of 

cases.  As  local  causes,  lack  of  cleanliness,  neglect  of  treatment,  and  im- 
proper treatment,  have  been  accredited  with  a  fair  share  of  the  blame  in 
its  production.  It  is  probable  that  phagedsena  is  a  personal  idiosyn- 
crasy, not  existing  continuously  in  a  given  patient,  and  aggravated  by 
those  causes  which  have  generally  been  considered  capable  of  generat- 
ing it. 

When  a  chancroid  is  attacked  by  gangrenous  phagedsena  the  tissues 
beneath  it  swell  up  and  become  livid  for  a  distance  around.  The  pus 
gets  scanty  and  sanious.  The  ulcer  grows  larger  and  dryer;  a  slough, 
gray,  brown,  black,  promptly  forms  upon  it ;  the  part  becomes  excessively 
painful;  the  slough  separates  promptly  or  slowly,  according  to  its  thick- 
ness ;  and  then  comes  a  lull  in  the  process. 

After  a  rest  of  longer  or  shorter  duration  a  new  attack  of  pam  an- 
nounces the  commencing  formation  of  a  new  slough,  and  the  process 
repeats  itself.  Large  excavations  in  the  tissues  are  thus  caused,  for 
sloughing  phagedsena  spares  nothing.  It  does  not  dissect  out  the  vessels 
or  arrest  itself  at  a  barrier  formed  by  a  new  tissue.  It  may  sweep  away 
the  penis  in  the  male,  destroy  the  labia  and  perineum  in  the  female,  make 
the  most  extensive  ravages  before  its  fury  is  appeased.  It  may  even 
endanger  life  by  exciting  peritonitis  when  ulcerating  deeply  over  the 
abdomen,  or  by  giving  rise  to  profuse  hemorrhage  by  cutting  through  a 
blood-vessel.  It  may  wear  out  the  sufferer  by  pain,  and  all  the  symp- 
toms of  general  septicaemia,  fever,  exhausting  diarrhoea,  and  debilitating 
sweats. 

The  poisonous  chancroidal  quality  of  these  ulcers  remains,  as  has  been 
tested  by  inoculation ;  yet  a  part  of  the  poisoned  surface  seems  to  grow 
tolerant  of  the  virus  after  a  time. 

Serpiginous  phagedsena  is  milder  in  all  respects  than  the  sloughing 
variety,  but  is  more  chronic.  The  former  exhausts  itself,  yields  to  treat- 
ment, or  kills  the  patient  within  a  reasonable  period,  while  creeping 
phagedsena  seems  to  have  little  or  no  reaction  upon  the  general  health,  is 
not  attended  by  much  pain  or  any  fever,  and  yet  continues  sometimes 
almost  indefinitely.  A  phagedenic  chancroid  o*  fourteen  years'  duration 
was  reported  by  Fournier. 

Serpiginous  phagedsena  commences  as  a  swelling  at  the  borders  of  the 
chancroid,  which  appear  more  red  than  usual,  and  as  the  connective  tissue 


THE   COMPLICATIONS   OF   CHANCROID.  189 

is  destroyed  by  gangrene,  the  borders  of  the  ulcer  become  largely  under- 
mined. The  remaining  bridges  and  their  flaps  of  livid  skin,  perforated 
here  and  there  where  the  ulcerative  action  has  eaten  through  to  the  sur- 
face, make  pockets  and  sinuses  around  the  ulcer,  some  of  which  extend 
long  distances.  In  this  manner  all  the  integument  of  the  penis  may  be 
dissected  up,  large  pouches  run  down  the  thigh  and  around  the  crest  of 
the  ilium,  or  (more  rarely)  up  over  the  abdomen. 

As  one  side  of  the  ulcer  advances  the  other  generally  heals,  and  thus 
the  ulcer  creeps  for  months,  perhaps  for  years,  over  the  surface.  The 
base  of  the  sore  retains  its  chancroidal  appearance.  It  is  uneven,  gray, 
covered  with  adherent,  pultaceous  secretions, 'and  occasional  prominent, 
flabby  granulations  bleeding  at  the  slightest  touch.  The  discharge  is 
watery,  bloody,  usally  free,  occasionally  scanty. 

Periods  of  rest  of  greater  or  less  length  occur  during  the  progress  of 
phagedaena,  when  the  ulcer  remains  stationary,  or  even,  perhaps,  seems 
to  be  healing  all  around;  and  then,  without  apparent  cause,  the  phage- 
denic  action  will  commence  again  at  one  border,  while  cicatrization  goes 
slowly  on  undisturbed  at  the  other.  Phagedaena  once  seen  cannot  after- 
ward be  confounded  with  anything  else. 

The  bubo  attending  phagedenic  chancroid  may  be  a  simple  one  or 
may  be  virulent,  and  itself  take  on  phagedenic  action.  Phagedsena 
seldom  attacks  simple  inflammatory  bubo. 

Treatment. — All  possible  improvement  in  the  hygienic  surroundings  of 
a  patient,  a  generous  and  varied  diet,  and  internal  tonic  measures  are  of 
value  in  treating  phagedsena.  Cod-liver  oil,  if  it  can  be  digested,  quinine 
in  large  doses,  especially  in  the  depressing  fever  of  sloughing  phagedaena, 
and  iron,  are  suitable  remedies.  Custom  has  sanctioned  the  preference 
for  Kicord's  tartrate  of  iron  and  potassium,  in  gr.  x.-xx.  doses  in  solution, 
as  a  tonic.  Kicord  thought  it  was  nearly  a  specific,  and  some  cases  cer- 
tainly do  well  upon  it.  The  pain  if  great  is  to  be  relieved  by  opium. 

The  local  treatment  is  more  important  than  the  general,  and  both 
forms  of  phagedaena  require  the  same  local  measures.  Total  destruction 
of  all  the  tissues  involved,  and  extending  widely  beyond  the  immediate 
area  of  disease,  is  certainly  the  best  treatment.  This  cauterization  must 
be  a  severe  one.  It  will  not  destroy  more  tissue  than  the  ulcer  left  to 
itself  would  have  eaten  away,  and  an  imperfect  cauterization  will  do  more 
harm  than  good. 

The  ulcer  must  first  be  made  ready  for  cauterization.  Anaesthesia 
may  be  obtained  by  infiltrating  the  surrounding  tissues  with  cocaine  (four 
per  cent)  or  eucaine.  All  overhanging  bridges  and  flaps  of  undermined 
livid  integument  must  be  cut  away.  It  is  best  to  do  this  with  scissors, 
and  to  sear  the  bleeding  edges  at  once  with  a  Paquelin  cautery.  When 
all  sinuses  have  been  laid  open,  and  the  whole  ulcer  is  flat  and  exposed 
and  the  bleeding  arrested,  then  the  surface  should  be  washed  with  a  solu- 


jOyQ  VENEREAL  DISEASES. 

tionof  corrosive  sublimate  1:2,000,  or  two-per-cent  solution  of  carbolic 
acid,  and  dried  with  blotting-paper.  Next,  it  should  be  touched  all  over 
with  pure  carbolic  acid  and  dried. 

Nitric  acid  cannot  be  depended  upon  for  final  cauterization.  A  cer- 
tain depth  beneath  the  ulcer  must  be  destroyed  in  all  directions,  in  order 
that  it  may  prove  effective.  A  liquid  caustic  cannot  be  applied  uniformly 
over  the  whole  surface;  it  will  spare  the  elevations,  and  spend  its  force 
upon  the  depressions.  On  this  account  other  caustics  are  better. 

The  choice  lies  between  the  actual  cautery  and  a  caustic  paste.  The 
galvano-cautery  or  Paquelin  cautery  may  be  used  and  should  be  em- 
ployed with  the  utmost  deliberation  and  care,  so  that  the  entire  base  and 
surrounding  integument  for  one-fourth  of  an  inch  is  absolutely  charred, 
and  thus  a  cure  of  the  phagedsena  may  be  confidently  expected. 

Unfortunately,  but  few  phagedenic  sores  are  sufficiently  small,  or  so 
situated  as  to  be  certainly  totally  destroyed  in  this  manner  without  endan- 
gering surrounding  parts.  In  such,  case,  if  the  ulcer  is  suitable  for  cau- 
terization at  all,  a  caustic  paste  should  be  employed.  Either  the  chloride 
of  zinc  or  the  carbo-sulphuric  paste  may  be  used — preferably  the  former, 
freshly  made,  by  mixing  equal  parts  of  chloride  of  zinc  and  dried  flour 
with  a  few  drops  of  alcohol  to  the  consistency  of  a  paste.  This  is  to  be 
packed  and  crowded  into  all  the  uueven  crevices  and  irregularities  of  the 
surface  already  prepared,  as  directed  above,  and  thoroughly  dried  out. 
The  packing  is  done  with  a  small  wooden  spatula,  and  the  excavation  of 
the  ulcer  filled  in  even  with  the  surface  of  the  surrounding  integument  at 
the  edges,  but  not  laid  on  thicker  at  any  one  spot  than  one-eighth  of  an 
inch,  since  this  thickness  is  ample.  The  packing  is  covered  with  a  piece 
of  absorbent  gauze  or  lint  cut  to  fit,  the  surrounding  epidermis  is  greased 
with  vaseline  freely,  then  the  whole  surface  is  generously  dusted  with 
powdered  starch  or  lycopodium,  covered  with  a  thick  layer  of  absorbent 
cotton,  the  whole  retained  by  a  snug  Toller  bandage. 

Morphine  may  be  required  to  control  pain.  The  bandages  should  be 
removed  in  from  twelve  to  twenty-four  hours,  the  surface  washed  and 
dried  with  absorbent  cotton,  and  finally  dressed  with  a  mildly  carbolized 
wet  dressing,  or  any  other  simple  application. 

Bromine  solution,  1  :  3,  has  been  suggested  for  these  ulcers,  and  a 
saturated  solution  of  antinosine— the  sodium  salt  of  nosophen — but 
neither  of  these  means  has  been  generally  enough  employed  to  justify  a 
conclusion  as  to  its  exact  value.  The  methods  above  detailed  are  cer- 
tainly efficient  when  cauterization  is  justifiable. 

There  are  many  cases  of  bad  phagedaeua  in  which  cauterization  should 
not  be  attempted.  In  any  case,  when  the  whole  surface  cannot  be  laid 
bare  and  included  in  one  cauterization,  other  means  must  be  used.  This 
exception  covers  many  cases  of  vaginal  and  rectal  phagedaena — cases  in 
which  extensive  layers  of  integument  have  been  dissected  up,  and  cases 


THE   COMPLICATIONS   OF  CHANCROID.  191 

in  which  long  sinuses  exist  involving  too  extensive  destruction  of  tissue. 
Cauterization  is  not  applicable  when  there  is  danger  that  the  caustic 
may  do  harm  by  eating  in  too  deeply,  as  over  the  sheath  of  the  femoral 
vessels.  Finally,  if  thorough  cauterization  has  once  failed,  it  is  better 
to  try  other  means  before  resorting  to  it  again,  and  under  these  circum- 
stances the  occasional  application  of  the  lighter  caustics,  pure  carbolic 
acid,  or  bromine  1 : 3  in  glycerin,  may  freshen  up  the  surface  and  help 
to  cure  in  many  cases  in  which  thorough  cauterization  cannot  be  applied 
or  has  failed. 

When  cauterization  is  not  desirable,  powdered  iodoform  was  formerly 
considered  the  best  local  application;  antinosine,  in  powder  form  or  a 
saturated  solution  as  a  wet  dressing,  is  also  to  be  recommended.  The 
powder  or  solution  should  be  freely  applied  to  the  ulcer  and  should  be 
renewed  as  often  as  the  discharge  collects,  which,  together  with  disin- 
fecting washes  of  carbolic  acid  or  weak  chlorinated  soda  water,  is  an 
excellent  resource,  and  often  acts  favorably. 

The  method  of  treating  phagedenic,  syphilitic,  and  other  unhealthy 
sores,  by  intermittent  or  continuous  submersion  in  water,  has  been  followed 
by  some  exceptionally  good  results. 

The  names  of  Hebra  in  Germany,  Hutchinson  in  England,  and  Hem- 
ard  in  France  are  well  known  in  connection  with  this  treatment.  We 
have  seen  the  most  salutary  results  from  this  method  in  very  unpromis- 
ing cases.  The  reliable  results  which  have  been  published  certainly 
render  it  worthy  of  trial  in  severe  cases  of  phagedsena,  whether  attacking 
chancroid,  chancroidal  bubo,  or  a  syphilitic  sore. 

The  method  of  submersion  as  employed  by  Mr.  Cooper1  is  simple  and 
easy  to  carry  out,  while  its  effectiveness  can  hardly  be  doubted  after 
reading  the  report  of  cases  in  which  it  was  used. 

The  patient  is  made  to  sit  in  a  hip-bath,  or  other  convenient  bath,  so 
that  the  site  of  the  ulcer  may  be  entirely  submerged  for  from  eight  to  ten 
hours  a  day.  The  water  is  kept  as  nearly  as  possible  at  a  uniform  tem- 
perature of  98°  F.  Here  the  patient  quietly  remains  all  day.  In  the 
evening  finely  powered  iodoform  or  other  suitable  dressing  is  put  upon 
the  sore. 

On  the  following  morning  the  patient  enters  his  bath  without  disturb- 
ing the  dressing  of  his  local  ulcer.  The  water  of  the  bath  thoroughly 
soaks  these  dressings  and  removes  them  without  pain. 

A  purge  before  the  course  of  baths,  tonics,  and  any  other  appropriate 
internal  medication  during  their  use,  are  recommended. 

Some  excellent  cases  are  detailed,  showing  the  rapidly  favorable 
influence  of  the  submersion  in  from  two  to  thirteen  days. 

The  application  of  hot  water  at  as  high  temperature  as  can  be  toler- 

1  London  Lancet,  May  24th,  1879,  p.  731. 


192  VENEREAL  DISEASES. 

ated  has  also  been  employed  as  a  therapeutic  agent  in  the  treatment  of 
chancroid,  and  it  is  claimed  with  excellent  results. 

Chancroid  is  not  said  to  be  complicated  by  syphilis  when  a  patient 
with  syphilis  gets  chancroid.  The  term  is  applied  only  to  the  "  mixed 
chancre,"  when  both  poisons  exist  at  one  and  the  same  time  in  the  local 
sore  (p.  212) .  The  previous  existence  of  syphilis  in  a  patient  does  not 
at  all  modify  the  appearance  or  course  of  chancroid. 

LYMPHANGITIS  AND  BUBO. 

Lymphangitis. — Chancroidal  lymphangitis  is  not  a  frequent  complica- 
tion. The  lymphatic  trunks  rarely  become  implicated  without  simulta- 
neous bubo,  while  bubo  frequently  occurs  when  there  is  no  lymphangitis. 

Lymphangitis  attending  chancroid  is  of  two  varieties :  inflammatory 
and  virulent. 

Inflammatory  lymphangitis  attacks  one  or  more  of  the  lymphatic 
trunks  upon  the  back  or  sides  of  the  penis  which  become  thickened, 
mainly  by  inflammation  of  the  connective  tissue  surrounding  the  vessel. 
A  hard  cord  is  felt  under  the  skin,  with  perhaps  several  knotty  swellings 
along  its  course,  usually  sensitive  to  pressure,  sometimes  adherent  to  the 
skin,  varying  in  size  from  a  goose-quill  to  a  broad  band,  according  to  the 
extent  of  the  surrounding  inflammation,  sometimes  marked  upon  the  sur- 
face by  a  red  line.  This  hard  cord  may  extend  from  the  chancroid  a 
certain  distance,  or  may  be  traced  to  the  root  of  the  penis.  Sometimes 
it  is  found  only  toward  the  root  of  the  penis,  being  absent  in  front.  If 
the  superficial  lymphatics  are  also  involved,  the  skin  may  become  oedema- 
tous,  hot,  and  painful.  If  the  inflammatory  symptoms  run  high,  there 
is  a  corresponding  amount  of  general  reaction  in  the  way  of  fever,  etc. 

The  terminations  of  inflammatory  lymphangitis  are  by  resolution  and 
suppuration.  The  pus  in  the  latter  case  is  always  simple,  non- virulent, 
and  is  due  to  excess  of  inflammatory  action.  The  abscess  generally  heals 
promptly,  and  the  lymphangitis  always  gets  well. 

Virulent  lymphangitis  is  very  rare.  It  possesses  all  the  foregoing 
symptoms  in  a  high  degree,  and  goes  on  promptly  and  necessarily  to  sup- 
puration at  one  or  more  of  the  knotty  points  along  the  inflamed  cord. 
The  pus  discharged  is  auto-moculable  and  yields  chancroid.  The  ab- 
scesses at  the  suppurating  points  do  not  heal,  but  become  chancroids,  and 
require  to  be  treated  as  chancroids. 

Treatment. — Mild  cases  require  no  special  care.  If  pain  and  surface 
redness  run  high,  a  cool  astringent  or  evaporating  lotion  is  appropriate. 
The  aluminum  acetate  mixture  (see  p.  187)  is  a  favorite  application,  to 
be  used  in  the  form  of  a  wet  dressing.  The  patient  should  remain  in 
bed  with  the  penis  elevated,  and  not  hanging  down  between  the  thighs. 
Poultices  are  objectionable,  since  they  soften  the  epidermis  and  tend  to 


THE   COMPLICATIONS   OP  CHANCROID.  193 

increase  the  size  of  the  resulting  chancroid,  should  suppuration  ensue  and 
prove  virulent.  Abscesses  should  be  opened  promptly,  and  the  dressing 
frequently  changed.  They  get  well  shortly  under  wet  or  dry  antiseptic 
dressing  if  the  suppuration  be  simple ;  if  virulent  they  are  chancroids, 
and  must  be  treated  as  such. 

Bubo. — The  term  "  bubo,"  although  generally  confined  to  inflammatory 
enlargement  of  the  inguinal  or  crural  glands,  may  be  correctly  applied  to 
a  similar  condition  in  any  lymphatic  gland  in  connection  with  a  venereal 
ulcer. 

Taking  the  statistics  of  various  writers,  the  frequency  of  bubo  as  a 
complication  of  chancroid  is  between  nineteen  and  thirty-three  per  cent. 
The  inflammation  is  confined  to  the  ganglia  of  the  superficial  chain ;  the 
glands  nearest  the  ulcer  lying  below  Poupart's  ligament,  above  the 
sapheuous  opening,  are  most  often  involved. 

Bubo  usually  occurs  in  the  groin  corresponding  to  the  side  of  the 
penis  involved  by  the  chancroid — but  it  may  be  in  the  opposite  groin;  or 
double  bubo  may  occur  with  a  single  sore,  when  the  latter  is  located  ia 
the  region  of  the  frenum. 

Cause. — It  is  generally  held  that  neglect  of  treatment  and  uncleanli- 
ness  are  exciting  causes  in  the  production  of  bubo.  The  irritation  at- 
tendant upon  balano-posthitis  with  phimosis,  specific  and  non-specific 
urethritis  may  be  sufficient  to  produce  inflammatory  enlargement  of  the 
inguinal  or  crural  glands  of  a  mild  degree,  the  latter  conditions  as  well 
as  ulcerated  herpes  and  severe  balano-posthitis  may  be  productive  of  irri- 
tations of  such  an  intense  character  as  to  result  in  suppurative  bubo, 
especially  in  those  of  debilitated  condition  and  lymphatic  habit.  Ducrey 
claims  that  the  streptobacillus  which  bears  his  name  is  found  in  the  pus 
of  chancroiclal  bubo,  and  in  this  contention  he  is  sustained  by  those 
workers  who  confirm  his  views  regarding  the  specific  character  of  this 
organism.  Among  these  are  Welander, '  Krefting,2  and  Unna.' 

Deutsch  *  found  the  Krefting-Ducrey  bacillus  in  the  pus  of  three  cases 
of  bubo,  inoculations  from  which  produced  typical  chancroid.  In  thirty- 
four  cases  of  bubo  examined  by  him  in  which  the  bacillus  was  not  found 
inoculation  was  not  successful. 

In  many  cases  of  bubo  the  ordinary  pus  organisms  are  demonstrated, 
and  in  some  cases  the  pus  is  found  to  be  free  from  pyogenic  microbes. 
Many  authors  maintain  that  the  ordinary  pus  organisms  and  not  a  specific 
microbe  are  the  direct  cause  of  buboes ;  others  that  they  are  due  to  the 
poison  generated  by  pyogenic  micro-organisms.  In  view  of  the  bacterio- 
logical observations  made  by  Deutsch  and  others  it  is  likely  that  the  con- 

1  Archiv  fur  Dermatol.  und  Syph.,  1892. 
8  Ibid. 

3  Monatschrift  fur  prakt.  Dermatol.,  1892,  vol.  xiv.  et  al. 

4  Centralblatt  fiir  die  Krank.  der  Ham-  und  Sexual-Org  ,  1897,  pp.  354  and  424. 

13 


194  VENEREAL  DISEASES. 

elusions  of  all  of  these  authors  are  more  or  less  correct,  and  that  some 
buboes  are  caused  by  the  presence  of  ordinary  pus  organisms,  others  by 
the  absorption  of  the  chemical  products  or  toxins  of  these  bacteria,  while 
a  few  are  due  to  the  presence  of  the  specific  organism  of  chancroidal 
virus  resulting  in  the  production  of  the  so-called  virulent  bubo.  It  is 
again  claimed  by  some  that  this  last  form  is  not  due  to  the  propagation 
of  the  chancroidal  virus  through  the  lymphatics,  but  that  inoculation 
takes  place  after  the  bubo  has  been  opened.  While  this  may  be  the  case 
in  some  or  even  a  majority  of  instances,  it  certainly  is  not  invariably  true. 

There  are  two  distinct  types  of  bubo — simple  and  virulent.  A  simple 
bubo  is  that  form  which  occurs  in  connection  with  the  irritation  propa- 
gated along  the  lymphatic  radicals  in  connection  with  balanitis,  herpes, 
gonorrhoea,  an  irritated  syphilitic  chancre  or  chancroid.  A  sore  of  any 
kind  may  give  rise  to  it  in  a  subject  who  is  predisposed  by  being  run 
down  physically.  Chancroid  is  the  most  common  cause. 

A  virulent  bubo  may  arise  from  a  simple  inflammation  or  phagedenic 
chancroid,  and  is  so  called  because  it  takes  on  the  character  of  chancroidal 
ulceration ;  and  assuming  its  cause  to  be  the  specific  organism  of  this 
venereal  sore,  it  must  be  derived  either  by  propagation  through  the  lym- 
phatic channels  or  by  inoculation  after  the  bubo  has  been  opened. 

Simple  bubo  generally  occurs  early,  if  at  all  (in  connection  with  chan- 
croid), commencing  within  a  week  or  two  after  the  sore  is  fairly  under 
way ;  yet  it  may  occur  when  the  ulcer  has  nearly  run  its  course.  The 
immediate  determining  causes  are  often  fatigue,  excess,  mechanical  injury 
to  the  gland ;  but  chancroid  alone  may  cause  it  without  the  assistance  of 
any  of  these  additional  provocations. 

Generally  only  one  gland  is  affected,  or  one  gland  so  much  more 
prominently  than  the  others  that  the  latter  may  be  disregarded. 

The  symptoms  of  simple  inflammation  of  a  lymphatic  gland  are  at  first 
a  sense  of  stiffness  in  the  groin  and  a  slight  swelling  of  a  single  gland. 
The  gland  rolls  under  the  skin,  is  sensitive  to  pressure,  and  the  seat  of 
pain  upon  standing,  walking,  and  particularly  upon  going  upstairs.  As 
the  gland  increases  in  size,  the  pain  proportionately  increases.  The  skin 
finally  adheres  and  becomes  reddened ;  then  it  becomes  oedematous,  and 
a  central  soft  spot  appears,  indicating  suppuration.  Occasionally  the 
periglandular  tissue  suppurates,  the  gland  itself  undergoing  resolution. 
Left  to  itself,  the  abscess  opens,  discharges  for  a  varying  period,  accord- 
ing to  the  general  health  of  the  patient  and  the  condition  of  the  sore. 
Much  exercise  always  interferes  with  rapid  repair.  Occasionally  the  pus 
burrows  in  various  directions  beneath  the  skin. 

This  is  the  typical  inflammatory  bubo,  whether  it  occurs  during  the 
course  of  chancroid,  urethritis,  etc.,  or  is  of  idiopathic  origin.  Its  course 
may  be  arrested  spontaneously,  or  by  treatment  at  any  period,  even  after 
suppuration  has  been  established.  The  amount  of  fever  or  general  sys- 


THE  COMPLICATIONS  OP  CHANCROID.  195 

temic  disturbance  is  considerable  in  some  cases,  absent  in  others.  Sup- 
puration may  be  announced  by  chill.  Finally,  simple  bubo  may  be  com- 
plicated by  gangrene  or  erysipelas. 

Another  form  of  bubo,  which  is  known  as  indolent  or  strumous  bubo, 
occurs  generally  in  those  suffering  from  malnutrition  or  a  debilitated 
constitution.  This  bubo  is  often  double,  a  number  of  lymphatic  glands 
being  involved  on  each  side.  The  tumor  may  reach  the  size  of  an  egg  or 
a  small  orange,  be  attended  by  but  little  pain,  and  perhaps  no  appreciable 
systemic  disturbance.  The  adherent  integument  over  the  lump  is  thin, 
livid,  sometimes  shining,  usually  of  a  dead  hue,  sometimes  smooth, 
sometimes  irregular,  oedematous,  and  undermined. 

This  livid,  chronic  enlargement  in  the  groin  may  continue  for  weeks, 
possibly  for  months  unchanged,  occasioning  very  little  annoyance. 
Sometimes,  on  the  other  hand,  it  is  attended  by  considerable  pain.  A 
chancroid  may  have  healed  up  long  before  any  change  has  occurred  in  the 
buboes — sometimes  even  before  they  have  reached  their  full  development. 

The  pus  may  burrow  in  different  directions  slowly  under  the  skin, 
and  at  the  bottom  of  long  sinuses  other  little  livid  abscesses  may  form 
and  open  spontaneously,  leaving  rigid  fistulas  to  discharge  indefinitely. 

A  spontaneous  or  simple  bubo  arising  from  a  strain,  fatigue,  or  local 
injury  in  a  strumous  or  cachectic  person  has  nothing  to  do  with  syphilis 
and  no  connection  with  chancroid,  and  does  not  imply  either  of  the  latter 
diseases  any  more  than  does  a  suppurating  gland  in  the  neck.  Much  was 
formerly  written  of  this  bubon  d'emblee.  Its  claims  to  recognition  as  a 
venereal  malady  have  been  entirely  overthrown,  and  its  accidental  posi- 
tion in  the  groin  alone  gives  it  interest  and  prominence,  more  than  at- 
taches to  the  same  identical  lesion  when  it  occurs  spontaneously  in  the 
axilla. 

Virulent  bubo  may  arise  from  a  simple,  from  inflamed,  or  from  a 
phagedenic  chancroid.  There  is  no  certain  date  of  its  appearance.  It 
may  commence  very  late.  Occasionally  it  declares  itself  just  as  the 
simple  chancroid  from  which  it  arises  is  getting  well.  Sometimes  double 
bubo  exists  with  a  single  chancroid — on  one  side  a  simple  bubo,  on  the 
other  a  virulent. 

The  first  features  of  virulent  bubo  are  those  of  simple  suppurating 
adenitis  accentuated.  When  the  abscess  ruptures  or  is  opened  with  the 
knife  its  true  chancroidal  character  begins  to  appear.  The  opening  be- 
comes larger  by  the  slowly  advancing  ulceration.  The  borders  get  hard, 
livid,  undermined,  while  the  integument  surrounding  the  edges  assumes 
a  dusky  purple  hue,  perhaps  is  perforated  in  a  new  spot,  or  sloughs  away 
in  pieces.  The  bottom  of  the  abscess,  now  an  ulcer,  becomes  irregular, 
worm-eaten,  covered  with  a  pultaceous,  adherent  deposit,  discharging 
plentifully  a  purulent  secretion,  which  is  inoculable  upon  the  bearer. 

This  ulcer,  with  its  ragged,  abrupt,  ulcerated,  and  undermined  edges, 


-j^g  VENEREAL,  DISEASES. 

its  uneven,  pultaceous  floor,  and  auto-inoculable  discharge,  is  a  true  chan- 
croid.    The  pus  may  burrow  along  the  groin,  down  the  thigh,  or  upon 

the  abdomen. 

Phagedaena,  either  in  the  sloughing  or  in  the  serpigmous  form,  may 
attack  a  chancroidal  bubo.  The  latter  is  more  common,  and  usually  the 
origin  of  those  extensive  chancroids  which  last  for  so  many  years. 

A  phagedenic  bubo  may  have  originated  from  a  non-phagedenic  chan- 
croid, just  as  a  phagedenic  chancroid  of  the  penis  may  have  a  simple  bubo 

or  no  bubo  at  all. 

Treatment.— Simple  bubo  sometimes  may  be  aborted.  The  moment 
a  trifling  stiffness  in  the  groin  begins  to  be  felt,  and  a  single  gland  is 
found,  by  pressure,  to  be  the  sensitive  spot,  the  greatest  amount  of  rest 
possible  should  be  insisted  upon.  The  diet  should  be  moderated  in  con- 
formity to  the  rest  enjoined.  Stimulants  should  be  avoided.  A  laxative 
may  be  required.  The  chancroid  should  be  cauterized  at  once,  if  it  be  a 
sore  suitable  for  that  treatment. 

Iodine  does  not  seem  to  possess  any  value  in  aborting  simple  bubo, 
and  most  ointments  which  have  to  be  rubbed  in  with  the  fingers  lead  to 
as  much  harm  by  mechanical  irritation  as  they  do  good  by  virtue  of  the 
medicament  they  contain.  Belladonna  ointment  in  conjunction  with  the 
application  of  a  snug  spica  bandage  is  said  to  yield  good  results  in  some 

cases. 

Cold  applications  are  useless.  The  hypodermic  injection  of  carbolic- 
acid  solutions,  from  gr.  viii.-x.  to  the  ounce,  and  of  one-per-cent  solution 
of  benzoate  of  mercury  have  been  advocated,  the  former  by  M.  K.  Taylor,' 
the  latter  by  Welander,2  who  report  successful  results  by  the  use  of  these 
interstitial  injections.  These  methods  lack  general  indorsement. 

When  abortive  measures  have  proven  unsuccessful  or  when  abscess  of 
the  gland  forms  promptly,  in  spite  of  efforts  to  arrest  it,  flaxseed  poul- 
tices may  be  employed  to  encourage  suppuration.  At  this  stage  drainage 
is  obtained  by  simple  incision,  or  total  extirpation  of  the  hyperplastic 
glandular  structures  is  effected  by  curetting. 

After  evacuation  of  the  abscess  the  resulting  cavity  is  treated  as  an 
ordinary  suppurating  wound  with  antiseptic  lotions,  such  as  corrosive 
sublimate  1:2,000,  or  carbolic  acid  1:50,  being  dressed  daily,  carefully 
packed  with  absorbent  gauze,  and  granulation  encouraged  by  the  aid  of 
balsam  of  Peru  or  other  stimulating  applications.  A  five-per-cent  mix- 
ture of  the  balsam  and  castor  oil  is  useful  here,  as  it  is  in  other  granulat- 
ing wounds. 

Hadyen"  advocates  the  use  of  ten-per-cent  iodoform  ointment  in  the 

1  American  Journal  of  the  Medical  Sciences,  April,  1882. 

1  Archiv  fur  Dermatol.  und  Syph.,  1892. 

3  Chicago  Medical  Journal  and  Examiner,  September,  1886. 


THE   COMPLICATIONS   OF   CHANCROID.  197 

abscess  cavity  after  it  has  been  irrigated  and  cleansed  with  peroxide  of 
hydrogen  and  bichloride  of  mercury.  His  report  of  cases  gives  an  aver- 
age duration  of  eighteen  days. 

Another  method,  advocated  by  Howland,  of  Washington,  substitutes 
for  iodoform  vaseline  the  preparation  known  as  glutol-Schleich  or  forma- 
lin gelatin.  This  author  packs  the  abscess  cavity  with  the  above  prepara- 
tion, which  is  left  in  situ  without  redressing  for  six  days.  He  reports  an 
average  duration  of '  eleven  days,  the  shortest  being  six  and  the  longest 
eighteen  days. 

Complete  extirpation  of  buboes  has  been  advocated  by  several  writers. 
Howland '  adopted  this  method  in  four  cases  in  which  it  required  from 
two  to  twenty-eight  days  to  effect  a  cure.  It  is  obvious  that  in  most 
cases  of  simple  bubo  this  method  has  nothing  to  recommend  it  in  prefer- 
ence to  other  less  radical  procedures.  This  does  not  apply,  however,  to 
the  treatment  of  the  indolent  or  strumous  bubo.  In  such  cases  much 
valuable  time  may  be  gained  to  the  patient,  together  with  improvement 
in  the  general  health,  by  complete  extirpation  of  the  diseased  glands.  A 
general  anaesthetic  should  be  administered,  all  pockets  and  sinuses  laid 
freely  open,  and  the  diseased  and  infiltrated  tissues  dissected  out  or 
scraped  with  a  sharp  curette.  All  the  exposed  glands,  whether  they  be 
apparently  healthy  or  not,  should  be  removed,  which  may  necessitate 
careful  dissection,  sometimes  as  deep  as  the  sheath  of  the  femoral  vessels 
or  even  between  them.  The  hemorrhage  is  sometimes  quite  profuse,  but 
is  readily  arrested  by  the  application  of  ligatures  and  subsequent  packing 
of  the  wound.  The  after-treatment  of  the  resultant  cavity  is  the  same 
as  that  following  the  incision  of  simple  bubo.  The  local  treatment  of 
the  indolent  form  of  bubo  should  be  supplemented  by  proper  internal 
remedies  in  the  form  of  tonics,  a  generous  diet,  and  cod-liver  oil. 

The  treatment  of  virulent  bubo  is  that  suitable  for  a  large  chancroid. 
Surgical  cleanliness  is  of  the  first  importance.  Cauterization  is  generally 
not  desirable.  The  entire  surface  and  abscess  cavity  should  be  copiously 
irrigated  with  strong  antiseptic  solutions.  Any  undermining  of  the 
borders  or  tendency  to  burrow  should  be  met  with  a  prompt  incision  to 
the  bottom  of  the  pouch.  The  cut  edges  may  become  ulcerated  and  the 
chancroid  enlarged,  but  this  is  preferable  to  the  formation  of  a  sinus. 
The  bottom  of  the  ulcer  should  be  more  thoroughly  cleansed  by  curetting 
and  removal  of  all  dead  tissues  and  sloughing  detritus.  Having  exposed 
the  entire  surface  to  the  free  access  of  local  remedies,  subsequent  treat- 
ment and  management  are  the  same  as  for  ordinary  chancroid. 

. '  "The  Cause  and  Treatment  of  Bubo,"  Medical  News,  November  26th,  1898. 


CHAPTER  IV. 

SYPHILIS. 
DEFINITION — ORIGIN — COURSE — GENERAL  PATHOLOGY. 

Definition. — Syphilis  is  a  specific  constitutional  disease,  acquired  either 
by  inheritance  or  by  contagion — generally  but  not  always  during  sexual 
intercourse.  It  is  characterized  by  the  appearance  of  a  primary  lesion  at 
the  seat  of  inoculation,  followed  by  periods  of  eruption,  varying  in  nature, 
severity,  and  duration.  The  earlier  symptoms  are  superficial,  the  latest 
involve  the  deeper  structures.  No  organ  in  the  body  is  exempt;  the 
connective  tissue  is  most  constantly  affected,  at  first  in  the  form  of  a  low 
chronic  inflammation,  and  later  as  the  seat  of  small  morbid  growths 
known  as  gummata.  Treatment  may  shorten  and  modify  the  disease; 
time  alone  can  wear  it  out.  A  perfect  recovery  is  possible. 

The  origin  of  syphilis  is  involved  in  impenetrable  darkness.  It  has 
been  the  subject  of  learned  essays  and  volumes.  Dr.  Buret  in  a  literary 
exposition1  upon  the  subject  affirms  that  it  was  known  among  the  Chinese 
two  thousand  years  before  Christ,  and  many  believe  that  it  has  existed 
in  all  countries  ever  since ;  that  it  was  known  to  physicians  of  ancient 
days  and  during  the  Middle  Ages,  although  its  nature  was  not  then  fully 
recognized.  Other  investigators  aver  as  emphatically  in  learned  writings, 
equally  founded  upon  fact,  that  the  disease  was  brought  from  America 
upon  the  ships  of  Columbus,  and  from  this  origin  spread  like  a  plague 
through  all  Europe. 

It  is  not  within  the  scope  of  this  work,  which  proposes  to  deal  with 
practical  questions,  to  enter  into  an  analysis  of  the  various  views  ex- 
pressed regarding  the  primeval  origin  of  syphilis. 

It  is  well,  however,  to  know  that  it  was  not  recognized  as  a  morbid 
entity  until  the  end  of  the  fifteenth  century,  at  and  after  the  period  of 
the  siege  of  Naples  (1494-95)  by  Charles  VIII. ;  that  then,  and  for  a 
considerable  time  thereafter,  the  disease  behaved  with  unwonted  viru- 
lence, attacking  all  classes  of  society,  and  killing  a  large  number  of  its 
victims.  From  that  time  to  the  present  day  syphilis  has  been  a  subject 
of  peculiar  interest  to  all  classes  of  medical  men.  It  enters  the  domain 
of  every  branch  of  pathology. 

Whatever  and  wherever  was  the  first  origin  of  syphilis  matters  little; 

1  "La  Syphilis  aujourd'hui  et  chez  les  Anciena,"  Paris,  1890. 


SYPHILIS.  199 

now  it  is  everywhere,  and  probably  spreading.     All  countries  on  the 
globe  possess  it. 

In  certain  parts  of  the  world  syphilis  is  said  to  be  exceptionally  mild, 
as  in  Portugal.  This  has  been  ascribed  to  the  fact  that  the  population 
are  saturated  with  syphilis,  and  owe  their  immunity  to  their  syphilitic 
forefathers.  In  certain  countries,  on  the  other  hand,  syphilis  is  said  to 
be  exceptionally  malignant — South  Sea  Islands,  Mexico.  The  acquisition 
of  syphilis  by  one  race  of  people  from  another  is  believed  to  produce  a 
severe  type  of  disease.  It  is  well  known  that  sailors  habitually  have  the 
disease  severely,  and  they  acquire  it  doubtless  often  in  foreign  ports. 

A  natural  deduction  from  these  facts  is,  that  finally  syphilis  will 
become  uniformly  acclimated  all  over  the  world ;  that  it  will  diminish  in 
severity  as  it  increases  in  extent,  and  perhaps  at  last  may  exhaust  its 
virulence  entirely.  Certain  it  is  that  the  syphilis  of  the  present  day  is 
not  the  syphilis  we  read  of  in  the  past.  Occasional  cases  of  malignant 
syphilis  and  bad  types  of  disease  still  appear  to  remind  us  of  what  the 
poison  can  do,  and  the  damaging  blight  which  the  inherited  taint  often 
inflicts  upon  its  innocent  victim  attests  the  continued  virulence  of  the 
malady.  In  a  majority  of  cases,  however,  in  reasonably  healthy  persons, 
the  type  of  the  disease,  as  encountered  at  the  present  day,  is  mild ;  it 
can  be  controlled  to  a  great  extent  by  treatment.  Thousands  of  individuals 
pass  through  it  unharmed  in  tissue,  in  feature,  in  function,  to  reach  a 
green  old  age  and  die  of  natural  causes,  leaving  behind  them  healthy 
offspring. 

Course. — After  contact  of  the  poison  with  a  surface  capable  of  absorp- 
tion, nothing  unusual  happens  for  several  weeks;  this  is  the  period  of 
incubation. 

The  lesion  which  first  appears  at  the  inoculated  point  is  called  a 
chancre,  whether  it  appears  upon  the  genitals,  the  fingers,  the  face,  or 
elsewhere — whether  it  is  a  dry  papule,  a  moist  tubercle,  or  an  excavated 
ulcer.  Within  two  weeks  of  its  appearance  the  neighboring  lymphatic 
glands  generally  become  slightly  enlarged  and  very  hard,  in  an  almost 
painless  manner,  many  glands  being  usually  involved  at  the  same  time. 
None  of  these  suppurate  as  a  rule.  The  appearance  of  the  primary  sore 
marks  the  beginning  of  the  second  period  of  incubation. 

Generally,  in  about  a  month  after  the  glands  enlarge,  after  the  second 
period  of  incubation  the  secondary  stage  commences,  an  eruption  appears 
scattered  more  or  less  uniformly  over  the  whole  body,  associated  with 
lesions  of  the  mucous  membranes  and  a  general  enlargement  of  the  lym- 
phatic glands  all  over  the  body. 

Just  before  the  outbreak  of  the  first  of  the  early  eruptions  some  pa- 
tients suffer  from  a  mild  amount  of  fever,  the  temperature,  generally 
moderate,  in  exceptional  cases  mounting  quite  high.  Kheumatoid  pains 
are  often  complained  of— worse  at  night.  Sometimes  there  is  headache, 


200  VENEREAL   DISEASES. 

a  general  fall  of  hair  is  often  noticed  (alopecia),  and  acute  iritis  may  be 
an  attendant  symptom. 

The  bodily  health  sometimes  fails  considerably  during  the  first  year, 
but  it  sometimes  remains  seemingly  undisturbed. 

At  the  end  of  a  year  or  more  there  is  a  natural  lull  in  the  course  of 
the  disease.  There  may  be  an  entire  absence  of  symptoms  for  many 
months.  In  very  exceptional  cases  the  lull  remains  permanent,  and  the 
patient  seems  to  be  and  to  remain  well  from  that  time  on.'  Usually, 
however,  after  a  period  of  quiescence  more  or  less  long,  new  outbreaks 
appear  upon  the  skin,  upon  the  fauces,  and  in  the  mouth.  Periosteal 
pains  in  all  the  superficial  bones  are  now  apt  to  make  themselves  felt, 
chiefly  at  night,  and  a  certain  amount  of  failure  in  general  health  is  cus- 
tomary. 

This  state  of  things  prolongs  itself  for  a  period  varying  from  a  few 
months  to  two  years  or  more,  and  terminates  by  leaving  the  patient  sound 
and  well,  or  by  merging  into  the  next,  the  tertiary  stage. 

In  the  last,  or  tertiary  stage,  the  symptoms  are  exceedingly  variable 
in  intensity  and  extent.  All  the  superficial  and  the  deep  textures  of  the 
body,  as  well  as  all  of  the  internal  organs,  may  be  involved.  The  lesions 
of  this  stage,  wherever  they  occur,  are  characterized  by  connective-tissue 
hyperplasia  or  by  gummatous  deposits,  and  in  either  case  by  thickening 
of  the  walls  of  arteries  within  the  pathological  areas.  In  the  skin, 
patches  of  tubercles  and  serpiginous  ulcers  appear.  Nearly  all  the  lesions 
leave  deep  scars.  The  throat  may  be  attacked  by  rapidly  destructive 
gummy  ulceration,  the  bones  of  the  nose  may  necrose  and  come  away. 
Ulcers  may  develop  upon  the  mucous  membrane  of  the  stomach  and 
intestine  and  impair  nutrition.  The  liver,  the  lungs,  the  kidneys,  the 
heart,  all  have  their  chance  at  suffering  from  tertiary  disease,  as  indeed 
do  all  the  internal  organs  and  tissues.  Nearly  all  known  chronic  diseases 
giving  symptoms  through  the  brain  or  through  the  nerves  may  be  simu- 
lated by  the  symptoms  of  tertiary  syphilitic  disease  of  the  brain  and 
nerves. 

The  bones  and  joints,  and  tendons,  and  bursse,  and  muscles  furnish 
appropriate  symptoms,  as  do  indeed  all  the  structures  of  the  body. 

After  yielding  symptoms  in  the  tertiary  stage,  more  or  less  severe  in 
type,  syphilis  in  course  of  nature  declines  spontaneously.  But,  before 
this  period  has  arrived,  such  vital  organs  may  have  become  involved  in 
permanent  changes  in  their  structure  that  health  is  no  longer  possible, 
and  sometimes  life  itself  cannot  be  sustained.  Death  as  a  direct  result 
of  syphilis  is  uncommon  in  the  adult,  but  may  be  produced  by  the  occur- 
rence of  structural  changes  in  the  vital  organs,  or  by  the  cachexia  of  the 
tertiary  stage.  Cachexia  is  one  of  the  marked  phenomena  of  this  stage, 
and  sometimes  seems  to  be  independent  of  obvious  organic  changes  in  the 
tissues. 


SYPHILIS.  201 

Syphilis  is  full  of  surprises  and  characteristic  irregularities.  No  two 
cases  exactly  resemble  each  other,  and  yet  the  family  likeness  is  quite 
strong  in  all.  Whole  groups  of  customary  symptoms  may  be  omitted 
during  the  evolution  of  the  disease.  Symptoms  may  be  strangely  out  of 
place.  Tertiary  manifestations  appear  in  precocious  cases  a  few  months 
after  chancre,  while,  on  the  other  hand,  erythematous  and  scaly  spots 
upon  the  palras,  the  soles,  and  in  the  mouth  may  crop  out  long  after  the 
tertiary  period  seerns  to  have  come  to  a  natural  end. 

General  Pathology. — The  changes  wrought  by  syphilis  upon  the  organs 
and  tissues  of  the  body  are  very  limited  in  number  and  very  uniform  in 
type,  but  the  symptoms  to  which  they  give  rise  are  as  varied  as  are  the 
functions  of  the  organs  and  tissues  involved. 

The  pathological  individuality  of  syphilis  shows  itself  in  the  various 
stages  of  the  disease  by  new  connective-tissue  production,  cellular  pro- 
liferation, and  in  the  formation  of  gummata.  These  lesions  involve  first 
the  subcutaneous  tissue,  later  the  walls  of  the  blood-vessels,  and  finally 
the  central  nervous  system. 

The  roseola  of  syphilis  is  largely  congestive ;  in  t"he  papule  there  is 
cellular  infiltration  as  well.  In  the  pustule  and  vesicle  there  is  exuda- 
tion of  pus  and  serum  beneath  the  epidermis.  The  later  cutaneous 
manifestations  are,  as  a  rule,  gummatous.  The  tubercles,  the  ulcers,  the 
gummata  of  the  skin,  are  all  essentially  different  varieties  of  gummatous 
infiltration.  They  all  undergo,  in  the  evolution  of  the  lesion,  retrograde 
changes — coagulation  necrosis — due  to  the  scarcity  of  blood-vessels  in  the 
areas  containing  them  and  to  disease  of  the  vascular  walls. 

Of  the  three  pathological  types  of  lesions  due  to  syphilis — new  growth 
of  connective  tissue,  arterial  thickening,  and  the  formation  of  gummata — 
the  connective-tissue  hyperplasia  plays  the  most  constant  role.  This 
tendency  shows  itself  throughout  the  entire  course  of  the  disease,  and  is 
the  basis  of  the  morbid  changes  which  take  place  in  all  parts  of  the  body. 

One  of  the  commonest  expressions  of  late  syphilis  is  the  production 
of  new  connective  tissue  in  the  central  nervous  system.  Its  elements, 
consisting  of  round  and  polyhedral  cells,  appear  in  patches  of  circum- 
scribed tissue,  accompanied  by  more  or  less  congestion.  Later  on  the 
blood  recedes  from  the  congested  vessels,  the  new  tissue  becomes  con- 
densed and  atrophies,  and  sclerosis  is  the  result. 

But  there  is  nothing  specific  in  this  form  of  connective-tissue  hyper- 
plasia. Other  forms  of  sclerotic  change  closely  resemble  it. 

The  gummy  tumors  or  gummata  are  characteristic  of  syphilis  and  be- 
long to  the  clinical  history  of  the  tertiary  stage.  They  are  formed  of  a 
collection  of  small,  soft,  round  cells,  which  lie  very  closely  crowded 
together  in  among  the  elements  of  the  other  tissues,  which  they  push 
aside. 

Such  collections  of  cells  may  develop  in  any  place  where  connective 


202  VENEREAL  DISEASES. 

tissue  and  blood-vessels  are  found— in  short,  almost  anywhere  in  the 
body.  Gummata  commence  to  form  usually  around  small  blood-vessels 
or  in  the  adventitia  of  large  ones,  and  are  found  of  minute  size  scattered 
along  the  fibrous  septa  of  an  organ  in  connection  with  more  or  less  general 
connective-tissue  hyperplasia,  or  as  a  single  large  nodule  of  independent 
formation. 

The  connective  tissue  around  a  large  gumma  becomes  condensed  and 
thickened  into  a  sort  of  fibrous  envelope;  its  central  portion  is  necrotic 
and  undergoes  caseous  degeneration.  This  is  either  due  to  lack  of  blood 
supply  or  to  the  action  of  toxins  produced  by  the  presence  of  specific 
micro-organisms,  the  nature  and  character  of  which  have  not  as  yet  been 
discovered. 

Gummata  situated  near  the  surface  generally  tend  to  act  like  abscesses, 
to  soften  centrally  and  then  ulcerate  their  way  to  the  surface,  discharge 
and  eliminate  themselves  in  the  form  of  gummy  ulcers. 

The  other  pathological  change  produced  by  syphilis  is  a  modification 
in  the  walls  of  the  blood-vessels.  We  find  the  vessels  surrounding  the 
primary  lesion  infiltrated  and  thickened  with  proliferated  round  cells. 
Such  a  condition  is  also  a  constant  accompaniment  of  all  inflammatory 
conditions,  but  especially  characteristic  here.  A  large  share  of  the  mor- 
bid phenomena  which  occur  in  brain  syphilis  is  due  primarily  to  changes 
in  the  walls  of  the  arteries  of  the  brain,  commencing  as  an  endarteritis, 
and  culminating  in  a  thickening  of  the  wall  of  the  vessel  and  obliteration 
of  its  calibre.  The  syphilitic  endarterial  changes  occurring  in  the 
different  large  arteries  of  the  body  result  in  thickening  of  the  arterial 
tunics  and  in  the  formation  of  thrombi.  Retrograde  metamorphosis  and 
gummata  lead  to  weakening  of  the  vessel  wall  and  are  a  direct  cause  of 
aneurism. 


CHAPTER   V. 

THE  TRANSMISSION   OF  SYPHILIS. 
METHODS  OF  CONTAGION — PROGNOSIS. 

THAT  syphilis  is  due  to  a  specific  virus  is  generally  conceded,  although 
its  nature  and  character  are  still  undergoing  investigation. 

An  assumption  of  a  specific  poisonous  quality  in  that  which  is  the 
essence  of  syphilis  serves  practically  to  assist  in  accounting  for  its  phe- 
nomena and  in  explaining  its  analogy  to  other  infectious  diseases. 

Secretions  which  Contain  the  Syphilitic  Poison. — The  thin  serous 
secretion  of  a  syphilitic  chancre  contains  the  poison  probably  in  as  con- 
centrated a  state  as  it  can  be  furnished  by  the  economy.  The  contagious- 
ness of  chancre  and  its  clinical  hetero-inoculability  in  kind  upon  a  virgin 
subject  have  never  been  doubted,  since  the  initial  lesion  of  syphilis  has 
been  recognized  as  the  starting-point  of  the  disease. 

The  contagious  properties  of  secretions  from  mucous  patches  and 
secondary  ulcerated  surfaces  upon  mucous  membranes  have  become  so 
obvious,  clinically,  that  it  is  questionable  whether  this  lesion  does  not 
divide  the  honors  of  propagating  syphilis  equally  with  chancre.  Mucous 
patches  and  mucous  tubercles,  ulcers  of  the  mucous  surfaces — all  these 
lesions  secrete  freely  and  are  in  a  position  frequently  to  be  brought  into 
contact  with  surfaces  capable  of  absorption.  The  long  duration  of  these 
lesions  makes  them  especially  dangerous.  They  last  for  months  at  a 
time,  and  relapse  frequently  while  the  syphilitic  chancre,  for  the  most 
part,  occurs  upon  a  patient  but  once  in  a  lifetime,  and  is  of  comparatively 
short  duration.  Abrasions  may  be  inoculated  during  sexual  contact  as 
well  from  a  mucous  patch  as  from  a  chancre. 

Nearly  all  the  examples  of  the  primary  lesion  of  syphilis  encountered 
upon  the  mouth  or  on  the  face,  the  primary  lesion  of  a  suckling  child 
derived  from  a  syphilitic  nurse,  of  a  healthy  nurse  from  an  infant  with 
inherited  disease,  the  cases  of  syphilis  acquired  from  using  spoons,  pipes, 
glass-blowers'  tubes,  those  communicated  by  the  surgeon  through  the 
instrumentality  of  the  Eustachian  catheter,  the  digital  chancre  of  the 
accoucheur — in  all  of  these,  quite  certainly  in  most  instances,  the  vehicle 
of  the  poison  has  been  the  secretion  of  a  mucous  patch. 

Hetero-inoculations  of  syphilitic  blood,  and  of  pieces  of  solid  tissue, 
which  of  course  contain  blood,  have  been  made  experimentally  by  a  num- 
ber of  physicians.  Some  of  the  inoculations  have  taken ;  others  yielded 


204  VENEREAL   DISEASES. 

only  negative  results,  showing  that  the  intensity  of  the  poison  in  blood 
is  not  particularly  great.  In  former  days,  before  the  present  advanced 
methods  of  vaccination  with  bovine  virus  were  employed,  epidemics  of 
"  vaccinal  syphilis  "  were  not  uncommon.  In  this  instance  the  blood  is 
the  vehicle  of  contagion. 

The  danger  of  transmission  under  the  same  circumstances  is  still  to 
be  feared  if  a  scarifying  instrument  be  used  in  vaccinating  and  proper 
antiseptic  precautions  are  not  observed. 

Clinically,  cases  are  encountered  in  which  blood  seems  to  be  the  vehicle 
of  contagion — in  which,  for  instance,  a  man  acquires  chancre,  and  confron- 
tation fails  to  detect  any  physical  lesion  in  the  female.  It  is  probable  that 
the  virulent  quality  of  the  blood  in  syphilis  moderates  in  the  later  stages 
of  the  disease  and  under  the  influence  of  treatment. 

The  secretions  from  tertiary  lesions  of  syphilis,  serpiginous  ulcers, 
lesions  of  bone,  etc.,  do  not  seem  to  retain  any  inoculable  quality,  so  far 
as  the  transmission  of  syphilis  is  concerned ;  but  with  the  tertiary  secre- 
tions, as  with  non-syphilitic  pathological  secretions  upon  syphilitic  per- 
sons, it  is  well  to  reserve  judgment  for  a  time.  They  may  possibly  be 
capable  of  carrying  the  poison  of  syphilis  without  admixture  of  blood; 
but  it  has  not  yet  been  proven  that  they  do  so. 

Of  the  physiological  secretions  it  may  be  quite  confidently  affirmed  that 
none  of  them  is  able  to  communicate  syphilis  by  inoculation. 

The  tears,  the  urine,  the  saliva,  the  perspiration,  the  milk,  the 
semen,  have  all  been  repeatedly  inoculated  without  success.  Some  dis- 
pute has  been  raised  upon  the  last  two  physiological  secretions  regarding 
their  power  of  inoculation. 

The  apparent  infections  by  milk  recorded  by  a  number  of  observers 
are  more  than  set  off  by  carefully  observed  cases  in  which  children  have 
suckled  syphilitic  nurses  and  remained  sound,  while  inoculations  of  milk 
directly  prove  its  lack  of  noxious  quality.  If  the  nursing  syphilitic 
woman  has  a  mucous  patch,  and  the  child  a  fissure  on  the  lip,  then  the 
whole  premises  are  changed,  and  chancre  on  the  lip  of  the  child  is  the 
natural  result. 

The  infectious  quality  of  semen  is  a  matter  of  serious  dispute,  both 
as  to  its  direct  contagious  properties  and  its  capacity  by  impregnation  to 
infect  the  offspring,  the  mother  remaining  healthy. 

The  evidence  at  best  is  only  negative.  A  little  blood  may  very  easily 
escape  from  an  abrasion  in  the  male  and  carry  the  poison  along  with  the 
semen.  The  mass  of  clinical  evidence  is  enormous,  going  to  show  that 
men  in  full  syphilis,  but  without  local  lesion,  may  have  intercourse  with 
impunity,  and  may  even  impregnate  healthy  women,  and  not  transmit 
syphilis  to  them  at  all,  or  even  to  the  offspring.  That  the  semen,  how- 
ever, can  transmit  syphilis  by  inheritance  seems  to  be  pretty  conclusively 
proved,  but  it  certainly  does  not  always  do  so. 


THE   TRANSMISSION   OP   SYPHILIS.  205 

In  connection  with  the  study  of  the  virus  of  syphilis,  and  of  the  fluids 
which  contain  it  and  may  transmit  it,  the  question  of  transmission  by 
inheritance  naturally  comes  to  mind. 

When  both  parents  are  diseased,  the  child  is  quite  certain  to  be  syph- 
ilitic, unless  the  poisonous  quality  of  the  malady  in  both  parents,  and 
especially  in  the  mother,  be  pretty  nearly  exhausted.  Cases  have  been 
recorded  in  which  the  child  appeared  sound  in  spite  of  disease  in  both 
parents ;  and  all  records  dealing  with  this  question  refer  to  cases  in  which, 
the  mother  being  diseased  and  producing  a  number  of  children,  some  of 
these  suffer  but  little,  if  at  all,  while  others,  born  later,  are  manifestly 
syphilitic.  It  is  certain  that  a  syphilitic  woman  under  treatment  may 
produce  a  child  in  all  respects  healthy,  and  then,  giving  up  medicine 
under  the  idea  that  she  is  well,  may  give  birth  later  to  a  child  about 
whose  syphilis  there  can  be  no  doubt. 

In  the  majority  of  instances,  syphilis  exhausts  itself  by  lapse  of  time 
in  the  mother,  and  her  children  become  less  and  less  likely  to  be  diseased. 

When  the  woman  alone  is  syphilitic,  the  child  is  quite  certain  to  in- 
herit the  disease.  Exceptions  to  this  rule  have  been  alluded  to  above, 
in  which  the  mother  has  syphilis,  then  produces  a  healthy  child,  then  a 
syphilitic  one. 

When  the  father  alone  is  syphilitic,  the  child  unquestionably  often 
escapes  if  the  mother  remains  well;  corroborative  cases  are  constantly 
turning  up,  and  there  can  be  no  reasonable  doubt  of  the  fact  that  a  healthy 
woman,  by  a  syphilitic  man,  may  have  a  healthy  child. 

But  that  a  healthy  woman  by  a  syphilitic  man  must  have  a  healthy 
child,  is  altogether  another  question,  and  certainly  is  not  a  fact,  if  there 
is  any  value  in  evidence. 

It  seems  fair  to  accept  as  proved  that  a  syphilitic  father  may  pro- 
create a  syphilitic  child,  and  that,  if  the  mother  at  the  time  of  conception 
is  healthy,  she  may  remain  so,  or  seem  to  remain  so,  indefinitely,  the 
child  being  born  syphilitic. 

This  statement  leaves  two  weak  points  unsatisfied  by  explanation. 
The  points,  both  negative,  are  these:  in  no  case  reported  has  it  been 
shown  that  a  healthy  mother,  who  had  produced  a  syphilitic  child  dis- 
eased from  its  father,  afterward  became  herself  poisoned  by  experimental 
or  accidental  inoculation.  The  other  point  is  this :  Colles'  law,  so  called, 
states  that  a  child  with  inherited  disease  may  poison  a  healthy  stranger 
whom  it  suckles  by  inoculating  the  breast ;  but  that  the  same  child  can- 
not poison  its  mother.  This  rule  cannot  possibly  stand,  unless  the 
mother  is  already  syphilitic,  or  unless  the  child  has  conveyed  to  the 
mother  an  immunity  to  the  disease.  No  authentic  instance  has  been 
recorded  in  which,  among  the  great  number  of  cases  observed,  any  excep- 
tion to  Colles'  law  has  been  noted.  Caspary  attempted  the  only  possible 
'  Vrtljhrschnft  f.  Derm.  u.  Syph.,  4tes  Heft,  1875. 


206  VENEREAL  DISEASES. 

positive  solution  to  this  question.  He  found  a  seemingly  healthy  woman 
with  a  syphilitic  husband  and  a  syphilitic  child.  He  inoculated  the  woman 
with  the  secretion  of  syphilis  without  effect,  thus  seeming  to  prove  that 
although  apparently  healthy,  she  already  had  syphilis. 

In  summary  of  the  foregoing  statements,  it  seems  just  to  conclude : 

1.  When  both  parents  are  syphilitic,  the  child  is  almost  necessarily 
diseased.     Exceptions  are  probable  under  treatment  of  the  mother,   or 
when  lapse  of  time  has  exhausted  the  disease  in  the  mother;  exceptions 
are  possible  during  lulls  in  the  disease,  or   under  circumstances   with 
which  science  is  at  present  unfamiliar. 

2.  When  the  mother  is  diseased  and  the  father  healthy,  the  child  is 
syphilitic,  excepting  under  the  same  circumstances  as  obtain  when  both 
parents  are  diseased. 

3.  When  the  father  is  diseased  and  the  mother  healthy,  the  child  may 
be  syphilitic  and  may  be  healthy.     Sometimes  the  child  is  diseased  under 
these  circumstances,  while  the  mother  seems  to  be  and  continues  to  remain 
well  in  all  respects,  as  testified  to  by  a  number  of  perfectly  competent 
observers. 

In  connection  with  this  question  of  the  transmission  of  syphilis  by 
inheritance,  three  other  points  must  be  considered,  namely,  the  date  at 
which  a  woman,  carrying  a  child,  may  become  syphilitic  without  poison- 
ing the  child;  the  "choc  en-retour"  of  Ricord;  and  the  transmission  of 
syphilis  to  the  third  generation. 

Unless  the  mother,  who  has  been  healthy  and  carries  a  healthy  child, 
gets  a  chancre  before  the  seventh  month  of  pregnancy,  it  is  believed  that 
her  child  will  escape  (Ricord,  Boeck,  Barensprung,  Frankel,  and  others). 

If  the  mother  gets  her  chancre  at  the  moment  of  conception,  or  soon 
after,  she  is  apt  to  miscarry.  If  she  gets  it  later,  the  child  goes  to  term, 
but  is  born  thoroughly  poisoned,  with  poor  chance  of  surviving.  The 
common  agreement  is  that  if  the  chancre  does  not  appear  before  the 
seventh  month,  the  child  is  safe.  This,  however,  is  not  always  the  case. 

Choc  en-retour  is  a  fanciful  expression,  meaning  that  a  healthy  woman 
conceives  by  a  syphilitic  man,  that  the  ovum  becomes  diseased  through 
impregnation  with  diseased  semen  and  in  its  turn  poisons  the  mother,  the 
latter  never  having  any  chancre,  but  becoming  contaminated  by  the  action 
of  toxins  circulating  through  the  blood  which  are  generated  in  the  infected 
fluids  of  the  foetus. 

The  possibility  of  choc  en-retour  reopens  the  whole  question  of  the 
inheritance  of  syphilis  from  the  father  alone,  already  discussed  above. 
The  possibility  of  this  method  is  seriously  doubted  by  many,  steadfastly 
believed  in  by  others.  It  will  stand  or  fall  upon  a  final  and  definite 
solution  of  the  question  of  inheritance  from  the  father  alone.  If  the 
father  can  transmit  syphilis  to  his  offspring  by  some  quality  his  malady 
has  imprinted  upon  his  spermatooza— and  there  is  no  reason  to  believe 


THE   TRANSMISSION    OF   SYPHILIS.  207 

that  this  is  impossible — then  it  is  very  probable  that  choc  en-retour 
exists,  and  that  the  prolonged  presence  of  the  child  in  utero  necessarily 
poisons  the  mother,  without  chancre,  giving  her  perhaps  a  modified  form 
gf  the  disease — not  enough  poison  to  betray  itself  by  the  usual  symptoms 
of  syphilis,  but  enough  to  protect  her  from  acquiring  the  disease  after- 
ward in  a  natural  way,  or  by  inoculation  (Caspary),  and  preventing  her 
child  from  giving  her  chancre  of  the  breast,  thus  justifying  Colics'  law. 

The  transmission  of  syphilis  to  the  third  generation  has  generally  been 
doubted.  Several  alleged  cases  have  been  reported,  some  of  which  seem 
to  be  unwarranted  assumptions,  while  in  others  the  history  is  incomplete 
and  unsatisfactory.  The  theory  that  syphilis  having  been  once  trans- 
mitted by  inheritance  degenerates  into  something  like  scrofula,  and  is 
transmitted  as  such,  cannot  be  sustained. 

Enough  evidence  from  different  quarters  has  not  been  collected  to  de- 
clare that  syphilis  may  be  transmitted  to  the  third  generation,  although 
such  a  possibility  is  not  out  of  the  question. 

Methods  of  Contagion, — The  methods  by  which  syphilis  may  be  ac- 
quired are  many. 

It  may  be  acquired  by  contact  of  a  surface  capable  of  absorption,  upon 
any  part  of  the  body,  with  the  poison  of  syphilis  contained  in  any  fluid 
capable  of  holding  it,  whether  it  be  upon  the  body  of  the  person  yielding 
the  poison  or  upon  some  indifferent  object.     Thus  its  transmission  may. 
occur  by  means  of  direct  or  mediate  contagion. 

Syphilis  acquired  by  sexual  intercourse  in  the  usual  way  is  an  instance 
of  direct  contagion.  The  surface  capable  of  absorption  upon  the  healthy 
person  is  brought  into  direct  contact  (usually)  with  the  source  of  the 
poison.  But  there  are  many  methods  of  direct  contagion  other  than  that 
by  sexual  intercourse.  As  illustrating  these  methods  may  be  instanced :  the 
chancre  of  the  lip,  acquired  by  kissing,  a  mucous  patch  being  the  source 
of  the  poison ;  the  digital  chancre  of  the  surgeon,  acquired  while  mani- 
pulating poisoned  parts ;  or  of  the  accoucheur,  acquired  while  practising 
the  vaginal  touch ;  the  chancre  on  the  nipple  of  the  healthy  nurse,  taken 
from  the  mucous  patch  in  the  mouth  of  the  syphilitic  child,  and  vice 
versa. 

As  aa  instance  of  mediate  contagion  the  following  example  may  be 
quoted:  A  married  man  with  a  long  prepuce  has  intercourse  with  a  former 
mistress.  He  returns  home  unwashed,  and  repeats  the  sexual  act  with 
his  wife,  leaving  in  her  vagina  some  syphilitic  secretion  which  he  had 
obtained  from  the  mistress,  and  carried  in  the  folds  of  his  prepuce. 
The  man  escapes  infection,  but  his  wife  acquires  chancre.  Spoons  and 
forks,  cups  and  tobacco-pipes,  tattooing-needles,  are  well-known  media 
of  contagion,  receiving  saliva  which  contains  the  secretions  from  mucous 
patches  in  the  mouth,  and  depositing  it  upon  a  fissure  in  the  lip  of 
another  person.  In  the  industry  of  glass-blowing,  the  passage  of  tha 


208  VENEREAL  DISEASES. 

tube  from  mouth  to  mouth  has  been  known  to  effect  a  widespread  distri- 
bution of  the  poison.  Vaccination  as  a  means  of  mediate  contagion  has 
already  been  noticed.  Surgical  instruments  have  sometimes  been  the 
medium  of  contagion.  Wet-cups  have  carried  the  disease,  the  transplan- 
tation of  teeth  has  done  the  same,  and  the  practice  of  the  religious  rite  of" 
circumcision. 

A  knowledge  of  the  variety  of  methods  by  which  syphilis  may  be  con- 
veyed is  of  great  value  to  the  patient,  who  is  ordinarily  ignorant  of  it. 
It  is  well  to  instruct  him  in  this,  as  well  as  to  give  him  directions  about 
the  local  and  general  treatment  of  his  disease,  so  that,  while  curing  him- 
self, he  may  know  how  to  preserve  those  by  whom  he  is  surrounded  from 
infection. 

Syphilitic  Reinfection. — It  is  notorious  that  a  patient  while  syphilitic 
cannot  take  the  disease.  Thousands  of  inoculations  have  been  made  upon 
such  patients  by  hosts  of  experimenters.  Protection  against  future  attacks 
is  secured  by  a  single  infection ;  and  yet  there  are  a  number  of  cases  on 
record,  resting  on  evidence  which  silences  criticism,  proving  that  true 
syphilis  may  be  acquired  twice  by  the  same  individual,  and  may  in  one 
lifetime  run  through  its  different  stages  twice.  It  follows  that  the  first 
syphilis  must  be  well,  or  the  second  could  not  have  been  acquired. 

Second  attacks  of  true  syphilis  unquestionably  do  occur.  This  fact  is 
not  more  strange  than  that  of  second  attacks  of  other  maladies,  such  as 
smallpox,  scarlet  fever,  measles,  vaccinia,  etc.,  one  course  of  which  gen- 
erally protects  a  patient  for  life. 

An  attentive  reading  of  many  cases  of  so-called  second  infection  makes 
it  clear  that  there  is  no  second  attack  at  all,  but  that  some  forms  of  pseudo- 
chancre  exist  which  are  not  at  all  uncommon,  such  as  ulcerated  gumma, 
herpes,  and  relapsing  induration  at  the  site  of  the  original  sore. 

While,  then,  it  must  be  granted  that  second  attacks  of  true  syphilis 
do  occur,  although  very  exceptionally,  it  is  fair  to  conclude  that  many  of 
the  reported  cases  are  instances  of  one  of  these  forms  of  pseudo-chancre, 
and  not  second  attacks  of  syphilis  at  all. 

Prognosis. — Practically,  in  the  majority  of  instances,  syphilis  is  a 
mild  disease.  It  gets  well,  to  all  intents,  under  a  variety  of  treatments, 
or  under  no  treatment  at  all  very  often ;  and  the  main  advantage  pos- 
sessed by  one  treatment  over  another  is  the  power  which  it  may  give  of 
immediately  controlling  symptoms  which  directly  threaten  life,  limb,  or 
functions,  and  the  guaranty  afforded  by  experience  in  its  use  against 
relapse  or  serious  disease  late  in  life. 

Therefore,  allowing  that  bad  cases  may  continue  to  relapse  almost 
indefinitely,  and  that  some  late  lesion,  due  to  syphilis,  may  occasionally 
appear  after  any  treatment  upon  a  patient  once  affected,  even  possibly  up 
to  the  hour  of  his  death,  yet  the  common  duration  of  the  disease  is  only 
about  two  and  a  half  to  three  years,  and  many  cases  do  not  have  symp- 


PROGNOSIS.  209 

torus  longer  than  during  a  few  months.  After  the  first  year  or  year  and 
a  half,  there  is  generally  but  little  trouble ;  and  when  the  disease  has 
fairly  died  away  the  patient  is  as  well  as  ever,  and  may  go  on  to  a  ripe 
old  age  without  ever  again  hearing  of  his  enemy,  having  healthy  children, 
and  passing  through  the  changes  incident  to  advancing  life  exactly  like 
any  one  else. 

Uncertainty  as  to  what  the  disease  may  eventually  do  interferes  seri- 
ously with  accuracy  of  prognosis  of  syphilis.  The  old  notion,  therefore, 
that  a  light  beginning  in  syphilis  can  be  counted  upon  to  indicate  a  type 
of  disease  in  itself  necessarily  mild,  is  not  accurate.  As  far  as  the  first 
symptoms  show  anything,  however,  they  do  in  a  measure  declare  the 
character  of  the  subsequent  symptoms,  but  they  do  not  guarantee  it;  the 
element  of  treachery  steps  in,  and  no  honest  prognosis  can  be  a  very 
positive  one. 

A  long  incubation  to  the  chancre,  mildness  in  the  primary  lesion,  a 
long  secondary  incubation,  mildness  in  the  earliest  eruption  (roseola)  are 
qualities  in  the  early  symptoms  which  generally  indicate  a  mild  type  of 
disease. 

On  the  other  hand,  a  short  incubation  to  the  chancre,  severity  in  its 
symptoms  or  the  duration  of  tin  latter,  intensity  in  the  local  character 
of  the  first  outbreaks  (pustular  instead  of  ery thematous) ,  and  resistance 
of  the  latter  to  treatment — particularly  that  form  of  disease  in  which 
symptoms  usually  occurring  in  the  tertiary  stage  come  on  early  in  the 
course  of  the  malady — all  of  these  features  in  the  beginning  of  syphilis 
indicate  severity  in  the  type  of  the  disease,  and  the  prognosis  must  be 
modified  accordingly. 

It  often  happens  that  cases  mild  in  the  quality  of  their  symptoms  are 
severe  in  regard  to  duration. 

The  influence  of  constitution  upon  the  course  and  the  type  of  syphilis 
is  very  obvious.  Two  persons  infected  from  the  same  source  do  not  have 
exactly  the  same  type  of  disease.  Both  acquire  identically  the  same 
poison,  but  the  symptoms  are  quite  certain  to  run  a  different  course. 

In  a  general  way,  it  is  true  that  a  healthy  person  in  good  hygienic 
surroundings,  living  a  regular  life,  is  best  able  to  stand  an  attack  of 
syphilis,  and  ought  to  escape  lightly ;  while  a  sickly  person,  in  bad  sur- 
roundings, should  by  right  be  overwhelmed  by  the  disease.  This  is  in 
a  measure  true,  but  exceptions  are  too  common  to  make  the  fact  of  much 
value.  A  vigorous  youth  in  the  flower  of  health  may  wilt  under  the 
blight  of  syphilis,  while  a  puny  consumptive  or  a  white-blooded  dyspep- 
tic suffers  very  little  more  while  the  disease  is  upon  him  than  he  did 
before  he  acquired  it. 

Despite  exceptions,  constitution  does,  on  the  whole,  modify  the  course 
and  intensity  of  the  symptoms  of  syphilis.     The  rheumatic  and  the  scrof- 
ulous tendencies  are  obvious  in  their  effects  upon  the  symptoms  of  the 
14 


210  VENEREAL  DISEASES. 

disease.  In  the  individual  of  so-called  gouty  habit,  the  evolution  of  the 
disease  is  slow,  the  type  of  eruptions  dry  and  scaly,  chronic,  relapsing, 
often  quite  superficial.  Pains  and  joint  troubles,  iritis,  and  bone  disease, 
arterial  complications  leading  to  brain  symptoms,  are  more  to  be  expected 
in  this  class  of  patients. 

The  condition  of  patients  with  phthisical  tendencies  is  nearly  always 
aggravated  by  an  intercurrence  of  syphilis. 

Patients  who  are  lymphatic,  and  who  readily  suppurate  from  injuries, 
the  effect  of  which  would  be  easily  thrown  off  by  another,  have  moist 
vesicular  and  pustular  lesions  early  in  the  disease  for  the  most  part,  and 
are  prone  to  run  early  into  ulcerative  lesions. 

Syphilis  influences  the  healing  of  fractures.  Cases  are  reported 
in  which  firm  union  was  delayed  until  the  patient  had  been  put  under  the 
influence  of  large  doses  of  the  iodide  of  potassium,  although  at  the  time 
the  patient  was  not  suffering  from  any  obvious  symptom  of  syphilis. 

Sometimes  ordinary  wounds  upon  a  syphilitic  person  fail  to  do  well, 
and  if  irritated,  assume  the  character  of  syphilitic  ulcers.  This  tendency 
is  decidedly  lessened  by  the  observance  of  strict  antisepsis  in  the  treat- 
ment of  all  traumatisms  upon  syphilitic  subjects. 

Prostrating  and  excessive  work,  irregular  habits,  excess  of  any  kind, 
dissipation,  bad  hygiene,  poor  food,  insufficient  clothing,  over-treatment 
(by  excess  of  drugs),  under-treatment  (of  too  short  duration),  no  treat- 
ment, bad  treatment — all  tend  to  aggravate  the  general  prognosis. 

Sex  also  influences  the  prognosis.  Women  are  more  apt  to  become 
anaemic  than  men,  and  to  grow  greatly  debilitated.  The  duration  of 
syphilis  with  them,  and  the  periods  of  latency,  are  seemingly  longer. 

The  age  of  a  patient  certainly  influences  prognosis.  The  activity  of 
the  disease  is  very  great  in  babyhood,  and  young  children  very  frequently 
die  of  syphilis,  inherited  or  acquired.  Old  people,  on  the  other  hand, 
have  less  vitality  and  power  of  resisting  disease,  and  syphilis  acquired  in 
advanced  life  is  therefore  often  severe. 

The  truth  is  that  syphilis  is  in  most  cases  a  very  manageable  disease, 
and  prognosis  is  more  influenced  by  the  intelligence  exercised  in  treating 
it  than  it  is  by  all  other  circumstances  combined ;  but  there  are  occasional 
exceptions  to  this  rule,  as  there  are  to  all  others  relating  to  syphilis. 


CHAPTER  VI. 

THE  CHANCRE— PRIMARY  LESION  OF  SYPHILIS. 

THE  incubation  of  syphilis  is  that  period  of  rest  which  always  occurs 
between  the  absorption  of  the  virus  and  the  appearance  of  the  chancre  at 
the  spot  where  absorption  took  place.  This  is  termed  ihe  first  period  of 
incubation.  Its  average  duration  is  twenty-one  days,  and  it  has  been 
known  to  occupy  nearly  all  the  intermediate  points  between  ten  and 
sixty,  or  even  seventy  days ;  but  such  long  periods  are  decidedly  excep- 
tional. The  rule  is  that  the  disease  generally  makes  its  appearance  in 
the  primary  sore  within  four  weeks  after  exposure. 

This  local  outbreak  in  syphilis  always  occurs  at  the  point  of  entrance 
of  the  poison,  and  the  disease  continues,  apparently,  confined  to  this 
point  for  a  period  of  so-called  second  incubation,  after  which  the  symp- 
toms of  the  disease  become  generalized. 

The  initial  lesion  or  first  stage  of  syphilis  is  a  chancre,  which 
appears  after  a  period  of  incubation  upon  the  spot  at  which  the  poison 
was  first  absorbed.  It  occurs  clinically  under  a  variety  of  forms  which 
resemble  each  other  very  little.  There  is  indeed  nearly  as  great  a 
variety  in  the  local  expression  of  primary  syphilis  as  is  known  to  be  the 
case  in  secondary  syphilis.  Chancres,  as  encountered  clinically  upon  the 
male  and  female  genitals,  are:  (1)  the  raw  erosion;  (2)  the  superficial 
ulceration;  (3)  the  deep,  funnel-shaped  ulcer,  always  indurated;  (4)  the 
herpetiform  chancre ;  (5)  the  mixed  chancre.  The  syphilitic  chancres  of 
the  lip,  of  the  nipple,  of  the  general  integument  have  their  type-forms, 
and  also  chancres  of  the  urethra,  anus,  or  rectum. 

The  Raw  Erosion. — This  is  the  most  common  form  of  syphilitic  chancre. 
Most  estimates  place  its  occurrence  as  high  as  sixty  to  seventy -five  per 
cent  of  all  forms.  It  is  found  in  both  sexes  on  the  integument,  as  well 
as  upon  a  mucous  or  semi-mucous  surface.  It  is  of  variable  size  from 
that  of  a  small  split  pea  to  a  large  beefy  patch  as  big  as  a  copper  penny 
when  advanced  in  growth.  The  surface  may  be  any  shade  of  red,  occa- 
sionally a  light  subdued  pink.  Generally  the  color  approaches  a  livid 
purple,  and  later  on  becomes  coppery.  There  may  be  a  central  adherent 
false  membrane,  but  usually  the  surface  is  literally  raw ;  not  discharging 
pus,  not  ulcerated,  but  yielding  a  trifling  discharge  of  bloody  serum. 

In  shape  this  erosion  is  oval  or  irregularly  rounded ;  perhaps  it  may 
run  along  a  natural  fissure.  Several  may  occasionally  coexist  upon  one 
patient,  appearing  simultaneously.  Induration  of  these  erosions  is  com- 


212  VENEREAL  DISEASES. 

mon,  sometimes  partial,  sometimes  beneath  the  whole  surface,  often 
parchment-like  and  imperceptible  unless  the  whole  integument  at  the  seat 
of  the  erosion  be  lifted  up,  and  the  lesion  gently  pinched  laterally  between 
the  thumb  and  finger.  Sometimes,  on  the  other  hand,  the  induration  is 
very  prominent  and  bulges  up  above  the  surface  like  a  solid  tubercle, 
with  a  flat,  raw  top  (ulcus  elevatum). 

The  Superficial  TTlceration. — This  form  of  primary  lesion  is  very  com- 
mon, and  is  much  like  the  last  in  most  of  its  features.  In  fact,  many 
chancres  are  first  erosions,  then  ulcerate  superficially,  and  perhaps  later 
return  to  the  eroded  state.  The  only  difference  between  this  chancre  and 
the  erosion  is  that  this  form  is  ulcerated.  The  ulcer  is  slight,  its  borders 
are  adherent  and  sloping.  Its  underlying  induration  may  be  parchment- 
like,  is  more  apt  to  be  of  split-pea  variety,  or  there  may  be  an  elevated 
tubercle  with  a  dome-like,  ulcerated  cap.  Finally,  the  induration  may 
be  slightly  excavated  downward,  and  then  the  ulcerated  surface  is  cor- 
respondingly depressed.  The  floor  of  these  ulcers  is  grayish,  the  dis- 
charge scanty,  thin,  sero-purulent — perhaps  bloody. 

The  Hunterian  chancre,  formerly  looked  upon  as  a  type,  is  almost 
rare  enough  to  be  an  exception.  It  is  simply  a  very  pronounced  chancre 
of  this  last  variety,  in  which  the  induration  is  considerable  and  the  excava- 
tion proportionately  great.  The  chancre  is  a  large  mass  of  woody  in- 
duration, of  rounded  form,  in  the  centre  of  which  is  an  oval  or  rounded 
ulcer  extending  deeply  into  the  induration,  funnel-shaped,  with  a  pulta- 
ceous  floor,  adherent  sloping  edges,  and  yielding  a  thin,  moderate,  puri- 
form  discharge. 

Herpetifonn  chancres,  so  called,  consist  of  a  collection  of  chancrous 
erosions.  They  resemble  clusters  of  herpetic  vesicles  and  may  be  mis- 
taken for  them.  On  this  account  in  doubtful  cases  an  opinion  should  be 
guarded.  The  diagnosis  is  made  by  the  persistency  of  the  lesions,  mode- 
rate induration,  and,  later,  involvement  of  the  inguinal  glands. 

The  mixed  chancre  is  a  combination  of  the  two  sores,  the  chancroid 
and  the  syphilitic  chancre.  Each  sore  runs  its  course,  and  the  compound 
lesion  possesses  the  characters  of  both. 

A  mixed  chancre  may  result  from  the  inoculation  of  either  sore  upon 
the  other,  and  its  characters  will  be  correspondingly  modified  according 
to  the  period  of  development  of  either  sore ;  either  one  may  be  nearly  well 
before  the  other  gets  fairly  under  way.  If  the  compound  poison  is  in- 
oculated, the  chancroid  would  naturally  be  well  along  in  its  course  before 
it  assumed  any  syphilitic  features.  The  mixed  chancre  has  been  produced 
experimentally. 

Inoculation  of  the  secretion  upon  a  healthy  subject  clinically  may  pro- 
duce chancroid  alone,  or  mixed  sore. 

Chancre  of  the  general  integument  occurs  as  a  flattened  papule  or  ele- 
vated tubercle,  or  excoriated  patch,  or  a  moist,  flat  tubercle,  or  an  indu- 


PRIMARY   LESION   OF  SYPHILIS.  213 

rated  ulcer.  All  of  these  forms  have  been  seen  and  studied  in  connection 
with  experimental  auto-  and  hetero-inoculations,  and  they  may  be  en- 
countered clinically.  The  lesions  resemble  the  same  varieties  upon  the 
penis.  The  excoriations  are  often  in  part  or  totally  scabbed  over;  there 
may  be  nothing  more  than  an  insignificant,  dry,  scaling  papule  upon  the 
skin  to  mark  the  point  of  entrance  of  syphilis.  The  flat,  moist  tubercle 
resembles  exactly  the  condyloma — the  flat,  mucous  tubercle  of  the  skin. 
Finally,  a  superficial  or  a  deep  excavated  ulcer  may  mark  the  starting- 
point  of  syphilis  upon  the  skin,  and  in  such  case  the  induration  of  the 
ulcer  is  apt  to  be  quite  extensive. 

Chancre  of  the  lip  is  generally  a  globular  mass  of  induration  as  large 
as  a  marble,  with  an  excoriated  or  exulcerated  surface. 

Chancre  of  the  tongue  has  no  distinctive  characteristics,  but  resembles 
the  raw  erosion  found  upon  the  genitals.  It  is  generally  located  on  the 
dorsal  surface  and  sometimes  on  the  side  of  the  lingual  mucous  membrane. 
Its  surface  may  be  shiny  and  red  or  covered  by  a  membranous  film.  The 
submaxillary  glands  are  always  enlarged. 

Chancre  of  the  tonsil  is  not  of  frequent  occurrence.  When  it  does 
occur  it  is  characterized  by  a  thick,  indurated,  brawny  swelling,  some- 
times with  an  eroded  surface,  sometimes  ulcerated  and  covered  with  a 
whitish  or  greenish  exudation. 

Chancre  of  the  nipple  acquired  by  nursing  a  syphilitic  child  may  be  a 
large,  deep,  indurated  ulcer,  a  brawny  excavation,  an  excoriated  or  ulcer- 
ated, indurated  fissure,  or  a  flat,  mucous  papule  more  or  less  livid,  moist, 
or  dry,  scaly  or  scabbed,  sometimes  but  little  indurated. 

Urethral  chancre  may  be  observed  through  the  endoscopic  tube  in  the 
form  of  a  rounded  erosion  or  flat  ulcer.  Generally,  urethral  chancre  is 
situated  just  within  the  meatus,  one  or  both  lips  of  which  it  may  involve. 
Occasionally,  however,  it  occurs  at  a  considerable  distance  within  the 
canal. 

Sometimes  the  existence  of  urethral  chancre  is  disclosed  by  the  presence 
of  a  lump  along  the  course  of  the  urethra,  usually  painful  upon  erection. 
At  this  spot  some  pain  is  apt  to  be  complained  of  on  urinating.  A  slight 
discharge  flows  from  the  urethra,  more  mucoid  than  purulent,  sometimes 
bloody.  This  discharge  commences  at  a  considerable  interval  after  the 
sexual  contact  to  which  it  was  due.  The  slight  discharge  continues  for  a 
number  of  weeks,  and  the  scar  left  by  the  chancre  may  subsequently  occa- 
sion more  or  less  stricture  of  the  urethra.  The  inguinal  ganglia  are  in- 
dolently enlarged  and  indurated. 

Chancre  of  the  fingers  occurs  at  the  site  of  an  abrasion  or  hang-nail  on 
the  hands  of  surgeons  or  nurses.  The  notable  feature  of  such  a  sore  is 
the  great  amount  of  thickening  surrounding  it,  with  an  absence  of  definite 
ulceration.  The  surface  is  raw,  shiny,  red.  The  epitrochlear  and  axil- 
lary glands  are  indurated  and  enlarged. 


214  VENEREAL  DISEASES. 

Chancre  of  the  anus  is  found  around  the  margin  of  the  sphincter  in 
one  of  the  folds.  On  this  account  and  because  the  induration  is  not 
generally  great,  this  lesion  may  go  unnoticed.  As  an  irregular  ulcera- 
tion  or  erosion  it  approaches  in  type  a  similar  lesion  on  the  general 
integument. 

In  the  female,  around  the  ostium  vaginae  and  on  the  labia,  erosions, 
often  not  appreciably  indurated,  excoriations,  flat,  raised  mucous  tuoer- 
cles,  and  the  regular  deep  indurated  ulcer,  may  each  be  encountered  as 
the  herald  of  future  syphilis. 

Upon  the  cervix  uteri  the  chancre  usually  appears  on  the  anterior  lip 
as  an  elevated  or  flattened  erosion,  with  a  red  areola  and  covered  with  a 
membranous  pellicle. 

Course. — The  first  evidence  of  inoculation  of  syphilitic  virus  upon  the 
skin  of  a  healthy  subject  is  a  flat,  dry  redness,  or  a  raised,  hard  papule, 
red  on  top.  Generally,  upon  a  mucous  membrane,  an  excoriation  or  a 
small  superficial  ulcer  is  found  from  the  start.  Sometimes  a  mass  of 
induration  forms  first,  and  this  afterward  excoriates  or  ulcerates.  On  a 
mucous  membrane  a  vesicle  or  a  pustule  may  precede  the  shedding  of  the 
cuticle  which  leads  to  the  excoriation,  but  its  existence  is  ephemeral. 
Induration  of  the  base  may  precede  the  breakage  of  the  cuticle,  and  be 
excessive  as  compared  to  the  latter ;  or  the  opposite  condition  may  obtain, 
there  being  considerable  ulceration  after  matters  have  progressed  for  a 
time  and  very  little  hardness.  Exceptionally,  the  whole  prepuce  becomes 
stiffened  with  a  cartilaginous  induration.  An  acute  livid  flush  of  the 
integument  may  precede  this  induration,  or  the  latter  may  form  gradually, 
especially  if  the  chancre  involves  the  prepuce  near  the  frenum. 

The  erosion  or  ulcer  increases  in  size  for  a  varying  period  and  to  a 
varying  extent;  from  an  erosion,  through  irritation,  it  often  becomes  an 
ulcer.  It  remains  unique,  not  poisoning  the  integument  in  the  neighbor- 
hood, and  not  giving  any  pain ;  yielding  its  watery  discharge,  attended 
by  its  lymphangitis  and  its  adenitis  in  the  second  week,  and,  after  last- 
ing from  two  or  three  weeks  to  as  many  months,  it  finally  gets  well,  leav- 
ing no  trace  in  most  instances.  If  the  ulcer,  however,  has  eaten  through 
the  papillary  layer  of  the  skin,  if  it  has  been  phagedenic  at  all,  then  a 
scar  is  left,  proportionate  in  extent  to  the  amount  of  tissue  destroyed. 
These  scars  often  remain  indurated  for  a  considerable  period.  They  are 
not  customarily  pigmented. 

Induration  is  a  feature  of  chancre  the  importance  of  which  has  been 
much  overrated.  It  is  not  an  absolute  essential  of  syphilitic  chancre, 
although  unquestionably  it  is  a  very  constant  symptom.  Induration 
occurs  in  several  forms : 

The  most  common  is  the  parchment-like  induration  found  underlying 
an  ulcer  or  an  erosion,  and  often  appreciated  with  difficulty,  unless  the 
ulcer  be  pinched  up  laterally  between  the  thumb  and  finger.  This 


PRIMARY  LESION  OF  SYPHILIS.  215 

variety  of  induration  is  common  in  the  female ;  it  is  rarely  simulated  in 
other  forms  of  disease ;  it  does  not  involve  the  subcutaneous  or  submucous 
tissues. 

The  next  form  is  characteristic,  but  not  very  common.  It  is  called 
the  split-pea  induration.  Immediately  underlying  the  ulcer  is  a  sub- 
stance of-  cartilaginous  or  woody  hardness,  like  a  split  pea,  convexity 
downward.  Its  size  varies  with  the  size  of  the  surface  lesion.  It  is  very 
nearly,  indeed  often  absolutely,  insensitive  to  moderate  pressure.  It 
does  not  shade  off  into  the  tissues  around  it.  It  is  not  adherent  to  the 
deep  fascia,  but  it  ends  abruptly  in  all  directions,  and  is  as  cleanly  de- 
fined as  would  be  a  foreign  body  set  into  the  skin  attached  to  the  ulcer 
by  its  upper  surface. 

The  last  form  of  induration  is  excessive.  It  resembles  the  previous 
variety  in  its  quality  and  behavior  as  to  the  surrounding  tissues,  but  it 
may  greatly  surpass  the  limits  of  the  surface  lesion,  be  convex  or  con- 
cave on  its  surface,  or  involve  irregular  areas  of  skin,  as  when  the  whole 
prepuce  or  a  portion  of  it  is  involved  in  a  wood-like  hardness  in  connec- 
tion with  chancre. 

Induration  often  precedes  the  breakage  of  the  skin,  and  very  often, 
when  it  has  been  excessive,  outlasts  the  healing  of  the  ulcer,  continuing 
perhaps  for  several  months,  or  in  the  scar  for  years.  It  may  be  of  only 
short  duration — ten  or  twelve  days,  coming  late  and  going  early.  The 
thin,  parchment-like  induration  is  the  most  transitory.  Once  com- 
mencing to  disappear,  induration  may  relapse,  and  occasionally  out- 
standing indurations  appear  in  the  neighborhood  not  connected  with 
the  initial  lesion,  but  formed  around  the  lymphatic  vessels,  and  these 
indurations  may  possibly  ulcerate  (Fournier).  Phagedsena  destroys  in- 
duration. 

Something  like  any  of  the  above  forms  of  induration  may  appear  with 
other  lesions  than  chancre,  and  indeed  upon  persons  not  at  all  syphilitic. 
It  is  never  safe  to  depend  upon  this  sign  for  a  diagnosis.  It  is  most 
valuable  as  a  corroborative  symptom,  and  more  constant  as  a  symptom 
of  syphilitic  chancre  than  any  other  one  symptom,  except  the  length  of 
the  period  of  incubation;  and  this  latter  may  be  unattainable.  Ordinary 
inflammatory  induration  generally  is  very  different  from  specific  indura- 
tion. It  is  red  on  the  surface,  painfully  sensitive  to  pressure,  adherent 
to  the  skin  and  the  parts  beneath,  losing  itself  gradually  in  the  subcu- 
taneous tissue,  with  no  clearly  defined  edge;  yet,  in  spite  of  all  the 
differential  characters,  syphilitic  induration  may  be  so  closely  simu- 
lated by  a  non-syphilitic  lesion  that,  alone  and  without  strong  cor- 
roborative evidence,  it  is  not  of  enough  value  to  establish  a  diagnosis 

syphilis.  . 

The  induration  of  a  small  gumma  of  the  semi-mucous  membrane  < 
the  prepuce,  as  appreciated  by  the  finger,  is  sometimes  absolutely,  anc 


216  VENEREAL  DISEASES. 

in  all  respects,  a  typical  induration  as  found  in  the  best-marked  cases  of 
syphilitic  chancre. 

Syphilitic  chancre  is  rarely  complicated.  Vegetations  may  grow  up 
around  it  and  its  new  surface  may  granulate,  or  may  take  on  a  whitish  or 
necrotic  pellicle.  Some  amount  of  inflammatory  disturbance  may  com- 
plicate the  ordinarily  indolent  and  undemonstrative  chancre,  leading  to 
its  swelling,  pain,  suppuration,  and  giving  to  it  some  of  the  features 
(auto-inoculability)  of  its  more  formidable  local  rival,  chancroid.  All 
of  these  complications  need  but  to  be  mentioned  to  be  understood.  The 
rarer  complication  of  chancre  with  chancroid  has  been  described  (mixed 
chancre). 

Phagedaena  complicating  syphilitic  chancre  occurs  usually  in  the  gan- 
grenous form.  If  the  whole  base  of  the  sore  is  involved,  the  induration 
disappears  in  the  phagedenic  process.  Sometimes  the  slower  form  of 
phagedsena  is  found,  but  generally  this  variety  is  not  very  extensive, 
when  complicating  a  syphilitic  primary  lesion.  A  description  of  both 
forms  of  phagedaena  has  already  been  given  in  connection  with  chancroid, 
and  nothing  further  need  be  added  here  except  an  allusion  to  the  fact 
that  mercury  internally,  although  harmful  to  phagedsena  occurring  upon 
the  patient  who  is  not  syphilitic,  is  decidedly  beneficial  to  the  phagedsena 
attacking  syphilitic  chancre. 

It  is  generally  believed  that  a  phagedenic  chancre  portends  a  bad  type 
of  syphilis,  and  this  is  doubtless  so,  since  phagedaena  is  not  a  quality  of 
the  peculiar  virus  with  which  the  patient  has  been  poisoned.  The  phage- 
daena is  due  to  the  patient's  own  quality  of  constitution,  and  it  is  fair  to 
suppose  that  such  a  constitution  will  suffer  from  an  attack  of  syphilis 
more  seriously  than  another. 

Lymphangitis. — This  consists  in  an  indolent  thickening,  with  indura- 
tion of  the  wall  of  one  or  more  lymphatic  trunks.  The  thickening  in- 
volves a  certain  amount  of  the  surrounding  perivascular  connective  tissue. 
These  rigid  cords  with  occasional  knots  upon  them  may  be  felt  along  the 
sides  or  back  of  the  penis,  sometimes  part  way  from  the  chancre  back- 
ward toward  the  root  of  the  penis,  sometimes  only  perceptible  near  the 
pubic  symphysis.  The  cords  vary  in  size  with  the  amount  of  infiltration 
of  the  walls  of  the  lymphatic  trunks,  and  are  larger,  according  to  the 
amount  of  perivascular  tissue  involved.  Very  rarely  the  inflammatory 
process  around  the  vessels  goes  on  to  suppuration.  Generally  the  lym- 
phangitis, if  it  occurs,  precedes  the  inguinal  adenitis  by  a  few  days.  It 
is,  as  a  rule,  painless,  and  of  not  the  least  importance.  The  integument 
over  the  thickened  lymphatic  trunks  is  not  reddened.  There  is  no  pecul- 
iar character  by  which  this  malady  may  be  known  from  a  chronic  mild 
lymphangitis  of  the  larger  lymphatic  channels  occurring  spontaneously, 
and  having  no  connection  with  syphilis  as  a  cause.  All  that  can  be  said 
of  syphilitic  lymphangitis  is,  that  if  it  occurs  with  syphilitic  (uninflamed) 


PRIMARY   LESION   OF   SYPHILIS.  217 

chancre,  it  is  very  certain  to  be  peculiarly  indolent  and  painless,  and  to 
be  characterized  by  a  high  degree  of  induration.  Pathologically  the 
lymph  spaces  are  infiltrated  with  hyperplastic  exudation.  Syphilitic 
lymphangitis  requires  no  treatment. 

Syphilitic  Bubo. — The  first  set  of  lymphatic  glands  along  the  line  of 
absorbents  which  originate  in  the  neighborhood  of  the  initial  lesion  of 
syphilis  almost  invariably  become  the  seat  of  certain  changes  which 
stamp  them  with  peculiar  value  as  aids  to  the  diagnosis  of  the  nature  of 
the  primary  lesion.  The  bubo  of  syphilis  may  therefore  be  situated  any- 
where upon  the  body  where  there  is  a  lymphatic  gland,  provided  the 
radicals  of  the  lymphatic  trunks  leading  to  that  gland  originate  in  the 
neighborhood  of  the  chancre.  Thus  chancre  of  the  lip  has  its  bubo  under 
the  jaw;  chancre  high  up  on  the  cheek,  in  the  pre-aural  gland;  of  the 
hand,  in  the  epitrochlear  gland ;  of  the  breast,  in  the  axilla ;  of  the  penis, 
in  the  groin,  etc. 

The  syphilitic  bubo  almost  invariably  comes  on  during  the  second 
week  after  the  appearance  of  the  primary  lesion,  between  the  eighth  and 
eleventh  days  in  cases  of  experimental  inoculation.  One  gland  generally 
first  becomes  enlarged,  and  then  a  number  of  others,  until  (in  the  groin) 
a  cluster  of  altered  glands,  not  matted  together,  but  lying  separately,  are 
found,  constituting  what  has  been  termed  a  "pleiad,"  and,  when  typical, 
very  distinctive  of  syphilis. 

The  number  of  glands  in  a  pleiad  varies  from  two  or  three  to  six  or 
eight.  Where  there  are  many,  one  is  usually  larger  than  the  others. 
Generally  the  glands  in  both  groins  are  involved.  Each  of  the  little 
glands  of  the  altered  group  is  quite  hard,  round  or  oval,  painless  on  press- 
ure, not  adherent  to  the  skin  or  to  the  tissues  lying  under  or  around  it, 
and  each  is  entirely  distinct  from  the  others.  The  skin  lying  over  them 
is  not  reddened,  and  the  size  of  each  gland  varies  from  that  of  a  pea  to 
that  of  a  marble.  When  the  number  is  considerable,  the  size  of  each 
is  usually  smaller  than  when  there  are  but  few.  Occasionally,  instead 
of  the  pleiad  there  is  one  very  large,  hard,  oval  gland,  with  one  or  two 
quite  small  ones;  and  still  more  rarely  the  bubo  is  single,  an  enormous 
lump  as  large  as  an  egg  existing  in  one  or  both  groins.  These  lumps  are 
composed  of  a  mass  of  indurated  hyperplastic  tissue. 

The  swelling  of  these  glands  is  called  indolent  because  of  their  slow 
course,  their  painless  and  non-inflammatory  character.  Very  often, 
however,  when  they  begin  to  swell  they  are  slightly  painful ;  and  occa- 
sionally they  go  on  to  suppuration,  either  centrally  or  as  a  periglandular 
suppuration. 

While  the  syphilitic  bubo  is  generally  multiple,  in  certain  situations 
it  is  more  apt  to  be  single,  as  under  the  chin,  under  the  jaw,  at  the  elbow, 
although  in  the  latter  situation  there  may  be  a  secondary  pleiad  in  the 
axilla. 


218  VENEREAL  DISEASES. 

The  duration  of  syphilitic  bubo  varies  from  a  few  weeks  to  a  number 
of  mdnths.  Sometimes  the  glands  never  subside  to  their  original  size. 
They  are  almost  constantly  present  during  the  first  eruption,  and  at  this 
time  they  occasionally  grow  somewhat  larger  and  harder. 

The  treatment  of  syphilitic  bubo  is  that  of  general  syphilis.  No 
treatment  is  called  for  until  a  general  eruption  comes  on.  Local  measures 
are  useless.  If  pain  and  inflammation  appear  as  complications,  these 
symptoms  are  to  be  appropriately  met. 

Treatment. — When  once  the  syphilitic  poison  has  had  access  to  the  ab- 
sorbents, the  patient  from  that  moment  has  syphilis,  and  he  is  therefore 
diseased  in  his  whole  body  several  weeks  before  the  chancre  appears. 
The  folly  therefore  and  the  uselessness  of  destroying  the  primary  lesion 
with  caustics  or  with  the  knife,  and  of  any  abortive  measures  seem 
obvious. 

Excision  of  the  chancre,  with  the  possibility  of  effecting  a  cure  of  the 
disease  in  this  manner  has  been  advocated  upon  the  theory  that  the  poi- 
son, after  being  absorbed,  lies  latent  locally  throughout  the  period  of  in- 
cubation, and  then  commences  to  increase  in  quantity,  at  first  only  locally ; 
that  after  a  period  it  reaches  the  lymphatic  glands,  and  there  increases 
and  multiples  again,  remaining  local  in  its  new  position  until,  during  the 
period  of  secondary  incubation,  it  has  had  time  to  infect  the  general  sys- 
tem, after  which  it  becomes  general  and  manifests  itself  by  an  eruption. 
This  theory  is  not  sustained  by  recent  clinical  and  pathological  studies  of 
the  morbid  process  attendant  upon  syphilitic  infection,  which  have  demon- 
strated conclusively  the  absolute  futility  of  excision  of  the  chancre,  even 
with  the  adjacent  ganglia,  as  a  prophylactic  measure. 

The  same  conclusion  has  been  reached  regarding  the  early  use  of 
mercury  during  the  primary  stage  as  a  preventive  treatment  against  the 
general  development  of  the  disease.  It  is  not  only  hopeless  to  expect  to 
curtail  in  the  slightest  degree  the  progress  of  the  disease  by  such  a  course, 
but  it  is  believed  that  a  harmful  influence  may  be  exerted  thereby,  the 
later  lesions  becoming  severe  and  obstinate  to  treatment,  not  to  mention 
the  possibility  of  errors  in  diagnosis  which  may  involve  both  patient  and 
physician  in  a  serious  dilemma  fraught  with  doubt  and  uncertainty. 

The  best  course  to  adopt  then  for  the  primary  sore  of  syphilis  consists 
in  local  and  expectant  treatment.  The  parts  may  be  kept  clean  by  any 
mild  antiseptic  lotion  and  the  sore  treated  with  a  moist  or  dry  dressing. 
Black  wash  is  much  used.  This  is  more  suitable  in  the  advanced  stage 
of  the  ulcer.  A  mild  sublimate  soltion  (1  to  3  :  4,000)  is  not  inappro- 
priate. Calomel  is  used  as  a  dusting-powder  alone  or  in  combination 
with  equal  parts  of  bismuth  and  oxide  of  zinc.  When  the  chancre  shows 
a  tendency  to  irritation  and  suppuration  it  is  best  treated,  after  being 
properly  cleansed,  with  iodoform  or  one  of  its  substitutes,  among  which 
may  be  mentioned  iodol,  aristol,  europhen,  and  nosophen.  The  last  prep- 


PRIMARY  LESION  OF   SYPHILIS.  219 

aration  has  proved  very  satisfactory  and  is  especially  commended.  The 
mixed  sore  must  be  treated  like  a  chancroid. 

If  the  lesion  be  complicated  with  phimosis  the  treatment  should  be 
conducted  on  the  lines  laid  down  under  that  heading. 

[For  a  differential  diagnosis  between  chancre  and  chancroid  see  Chan- 
croid.] 


CHAPTER  VII. 

CONSTITUTIONAL   SYPHILIS. 

STAGES  OF  THE  DISEASE. 

SYPHILIS  is  not  a  continuous  chain  of  symptoms.  It  is  a  broken 
series  of  outbreaks,  varying  in  intensity,  in  duration,  and  in  the  length 
of  the  intervals  between  them.  During  these  intervals  the  patient  may 
seem  perfectly  well.  That  the  poison  continues  active  during  the  periods 
of  latency  (the  early  ones)  is  evident  from  the  fact  that  syphilis  has  been 
acquired  from  the  blood  of  a  subject  not  at  the  time  bearing  any  trace  of 
syphilis  upon  his  person ;  that  syphilitic  women,  during  periods  of  most 
absolute  latency,  have  brought  forth  syphilitic  children;  that  trauma- 
tisms  upon  syphilitics,  in  a  period  of  latency,  often  call  out  syphilitic 
lesions. 

Therefore  it  becomes  impossible  to  state  absolutely  that  the  disease 
is  naturally  divided  up  at  all.  It  may  be  one  continuous  malady  with 
remissions,  but  really  continuing  all  the  time.  Yet  facility  of  descrip- 
tion, custom,  and  the  peculiar  character  of  the  outbreaks  of  syphilis 
have  justified  its  division  into  stages,  and  these  stages  are  commonly 
known  as  primary,  secondary,  and  tertiary. 

The  primary  stage  is  all  that  portion  of  the  disease  lying  between  the 
moment  of  infection  and  the  time  of  appearance  of  the  first  general  erup- 
tion with  its  fever  and  general  ganglionic  engorgement ;  it  therefore  in- 
cludes the  initial  lesion  with  its  accompanying  lymphangitis  and  adenitis, 
as  described  in  the  last  chapter. 

The  Secondary  Stage. — As  soon  as  the  secondary  incubation  has 
passed,  secondary  syphilis  begins.  It  may  date  as  early  as  three  weeks 
from  the  time  of  appearance  of  the  chancre ;  it  generally  does  not  com- 
mence for  six  weeks  or  two  months,  and  may  be  delayed  much  longer, 
especially  if  mercury  has  been  used  in  treating  the  primary  stage.  Most 
of  the  symptoms  of  this  stage  are  superficial.  They  are  first  congestive, 
and  occurring  on  the  mucous  as  well  as  on  the  cutaneous  expansions. 
Gradually,  as  time  passes,  the  lesions  become  deeper  seated,  and  finally 
the  second  merges  so  gradually  into  the  tertiary  stage  that  it  is  impossible 
to  fix  upon  a  positive  boundary  between  them. 

The  duration  of  secondary  syphilis,  like  the  duration  of  the  whole 
disease,  varies  so  greatly  that  it  is  not  only  impossible,  but  even  unwise, 
to  attempt  to  confine  it  within  definite  boundaries.  In  a  general  way,  in 


CONSTITUTIONAL    SYPHILIS.  221 

most  cases  the  symptoms  merge  into  the  tertiary  forms  during  the  second 
year;  but  secondary  lesions  continue  in  many  cases  to  crop  out  occasion- 
ally in  the  third  year  or  later,  intermingled  with  the  deeper  lesions  of 
tertiary  stage.  It  is  not  at  all  uncommon  for  a  patient  with  a  gumma- 
tous,  destructive  ulcer  of  the  throat  to  have  also  upon  his  palm  a  super- 
ficial scaly  patch  very  similar  to  what  he  may  have  had  during  the  first 
year  of  his  disease. 

And,  on  the  other  hand,  but  more  rarely,  the  symptoms  legitimately 
belonging  to  tertiary  syphilis  occasionally  come  on  earlier,  and  appear 
among  the  secondary  symptoms.  Gummata  in  various  situations  may 
thus  appear  prematurely ;  nodes  on  bones,  advanced  symptoms  of  nervous 
disease,  hemiplegia,  epilepsy,  sometimes  show  themselves  at  the  end  of 
six  months,  and  are  followed  by  secondary  symptoms,  instead  of  appear- 
ing at  their  regular  time  about  the  second  year  or  later. 

The  tertiary  stage  commences  on  the  boundary  line  of  secondary 
syphilis,  about  the  second  year  or  sometimes  considerably  later,  and  em- 
braces everything  which  may  happen  afterward  due  to  the  disease.  The 
lesions  are  infiltrative,  gummatous,  often  destructive,  ulcerating,  and  in- 
clude most  of  the  connective-tissue  parenchymatous  changes  and  gummy 
deposits  which  involve  the  viscera. 

In  inherited  syphilis  the  symptoms  of  both  secondary  and  tertiary 
stages  are  customarily  more  or  less  combined.  The  child,  when  born, 
often  has  lesions  in  its  lungs,  liver,  kidneys,  thymus,  and  spleen,  with 
changes  iu  the  epiphyses  of  the  long  bones,  and  at  the  same  time  super- 
ficial, scaly,  erythematous,  papular,  and  excoriative  patches  upon  its 
integument  and  mucous  membranes. 

In  acquired  syphilis  the  whole  of  the  tertiary  stage  may  be  absent. 
The  disease  not  uncommonly,  under  judicious  treatment,  ceases  entirely 
at  the  end  of  the  secondary  stage,  and  the  patient  lives  for  years  without 
another  symptom,  raising  healthy  children,  and  himself  to  all  appear- 
ances well. 

The  secondary  incubation  period  commences  when  the  chancre  appears, 
and  ends  when  general  symptoms  come  on.  This  period  often  is  not  one 
of  latency,  strictly  speaking,  since  active  symptoms  of  syphilis  are  usually 
present  upon  the  patient  during  the  whole  of  it,  for  the  chancre  has  rarely 
healed  before  the  first  eruption  comes  out  (unless  treatment  keeps  it  back) ; 
and  even  if  the  chancre  has  gone,  the  inguinal  glands  are  certain  to  re- 
main engorged  during  a  much  longer  time  than  the  period  of  secondary 
incubation. 

The  length  of  the  second  incubation  in  untreated  cases  varies  from 
twelve  days  to  between  four  and  five  months;  but  commonly,  in  untreated 
cases,  it  lasts  about  six  weeks. 

During  the  second  incubation,  while  the  organism  is  becoming  satu- 
rated with  the  poison,  the  general  health  may  appear  flourishing,  or 


222  VENEREAL.  DISEASES. 

show  some  signs  of  falling  off,  yet  there  is  often  no  positive  failure  of 
health  until  the  eruptions  appear,  and  sometimes  no  obvious  failure  even 
then. 

SYMPTOMS  ATTENDING  THE  GENERAL  OUTBREAK  OF  THE  DISEASE. 

All*  descriptions  of  syphilis  refer  to  the  symptom  of  fever  as  being 
one  of  the  most  constant  accompaniments  of  the  constitutional  disease. 

It  comes  upon  the  patient  unawares  during  the  period  of  second  incu- 
bation, and  precedes  the  outbreak  of  the  first  eruption.  It  is  this  fever 
to  which  the  name  syphilitic  is  given. 

The  type  of  the  fever  may  be  continued,  remittent,  or  intermittent. 
It  may  consist  of  a  single  short  outburst,  or  may  last  for  days.  More 
rarely,  it  is  accompanied  by  great  prostration,  attended  by  headache  and 
epistaxis,  and  assumes  a  type  suggestive  of  typhoid  fever. 

Its  occurrence  is  by  no  means  uniform.  If  it  is  looked  for  by  aid  of 
the  thermometer,  it  will  be  often  found ;  otherwise  it  may  not  be  thought 
of  either  by  the  patient  or  physician,  excepting  in  a  minority  of  cases 
when  the  prostration  is  great  or  the  range  of  temperature  high. 

The  thermometer  rarely  marks  higher  than  102°  F.  in  syphilitic  fever ; 
104°  has  been  pretty  generally  considered  to  be  a  point  above  which  it 
does  not  go. 

The  symptoms  attending  the  fever  are  very  variable.  Anaemia  may 
be  quite  marked,  the  pallor  being  due  to  the  well-known  diminution  in 
the  haemoglobin  of  the  blood,  first  pointed  out  (1844)  by  Grassi.  Gen- 
eral depression  and  a  feeling  of  being  sick  are  common  complaints.  Pains 
in  the  bones,  in  the  joints,  under  the  sternum,  in  the  side  and  back,  in 
the  head,  all  of  them  worse  at  night,  are  apt  to  be  complained  of.  The 
night  headache  is  pretty  constant  and  sometimes  frightfully  severe,  the 
pain  coming  on  and  yielding  at  stated  hours,  often  with  great  regularity. 

When  the  fever  runs  high  and  an  eruption  appears,  the  mistake 
of  confounding  syphilis  with  measles,  or  even  with  smallpox,  has  been 
made. 

Jaundice  may  come  on  with  syphilitic  fever,  due  to  catarrh  of  the 
bile  ducts,  from  engorgement  of  the  mucous  membrane,  or  pressure  upon 
the  ducts  by  enlarged  glands. 

Pressure  upon  the  lower  third  of  the  sternum  will  sometimes  evoke  a 
pain  not  otherwise  complained  of,  and  the  anaemia  may  be  great  enough 
to  give  the  soft,  blowing  character  to  the  first  sound  of  the  heart. 

Syphilitic  fever  usually  disappears  soon  after  the  general  eruption 
oomes  out.  Its  own  special  features  are  so  varied  that  its  diagnosis  de- 
pends upon  the  previous  (or  actual)  existence  of  a  chancre  and  the  presence 
of  evidences  of  general  syphilis. 

During  syphilitic  fever,  or  at  the  beginning  of  general  syphilis,  when 


CONSTITUTIONAL   SYPHILIS.  223 

there  is  no  fever,  it  is  common  to  observe  other  symptoms  which  mark 
the  onset  of  the  secondary  stage.  These  need  not  be  fully  described  here, 
since  they  may  be  found  under  their  appropriate  heads ;  but,  before  going 
into  syphilis  as  affecting  the  tissues  and  organs,  it  is  well  to  mention  them 
in  outline. 

With  scabs  in  the  hair  and  the  mottling  of  the  skin  or  circumscribed 
eruptions  the  ganglionic  pleiad  in  the  groin  still  remaining,  and  perhaps 
the  chancre  being  still  raw,  we  may  find  that  one  or  both  epitrochlear 
glands  are  indolently  indurated,  resembling  the  glands  in  the  groin,  and 
certain  glands  in  the  posterior  chain  of  the  posterior  cervical  glands  may 
be  similarly  affected.  The  glands  most  characteristic  among  these  are 
those  lying  on  the  occipital  bone  on  either  side.  These  glands,  as  well  as 
the  glands  in  the  groin,  generally  disappear,  with  or  without  treatment, 
as  the  disease  advances,  and  it  is  not  well  to  depend  upon  them  to  corrob- 
orate syphilis  after  the  first  few  months. 

Another  symptom  is  a  generalized  falling  of  the  hair  (syphilitic  alo- 
pecia) .  The  hair  thins  out  over  the  whole  scalp,  does  not  fall  in  patches, 
and  with  this  there  may  generally  be  noted  a  tendency  to  a  fall  of  hair 
from  the  beard  and  eyebrows,  and  more  or  less  from  the  whole  body  in 
severe  cases.  This  alopecia,  however,  is  often  confined  to  the  scalp. 
When  the  hair  falls  late  in  syphilis,  if  the  falling  out  of  hair  is  general, 
it  is  due  to  cachexia ;  if  it  is  local,  it  is  due  to  a  local  physical  lesion 
(ulcer)  involving  the  papillae,  and  the  hair  does  not  generally  return  when 
the  disease  gets  well,  as  it  does  after  the  alopecia  of  early  syphilis. 

The  throat  symptoms — erythema  and  mucous  patches — to  be  described 
later,  are  very  characteristic,  and  should  always  be  looked  for  in  the  out- 
break of  general  syphilis. 

Certain  sympathetic  nervous  symptoms  have  been  spoken  of  which 
occur  more  particularly  in  women  early  in  syphilis — inability  to  distin- 
guish heat  from  cold,  anaesthesia  of  certain  limited  areas  of  skin,  marked 
coldness  of  the  hands  and  feet,  etc. 

Some  patients,  especially  women,  suffer  from  mental  disturbances, 
such  as  hallucinations,  delusions,  and  hysterical  manifestations. 


CHAPTER  VIII. 

THE   GENERAL   TREATMENT   OF    SYPHILIS. 

SYPHILIS  is  naturally  a  self-limiting  malady,  and  its  general  treat- 
ment may  be,  and  often  is,  left  entirely  to  nature.  Many  a  woman,  and 
occasionally  a  man,  gets  syphilis  without  knowing  it,  and  runs  through 
the  disease  into  health  without  any  specific  treatment  at  all.  Indeed,  it 
may  perhaps  be  justly  doubted  whether  treatment  of  any  kind  can  shorten 
the  duration  of  syphilis,  for  the  disease  will,  and  it  does,  crop  out  at 
remote  dates  after  any  and  all  kinds  of  treatment  (less  often  after  cer- 
tain kinds  of  treatment  than  after  others),  and  there  is  no  positive  and 
certain  test  which  can  be  applied  to  a  person  to  determine  whether  he  is, 
after  treatment,  free  from  the  disease  or  not. 

There  is  no  doubt  whatsoever  that  certain  drugs  restrain  the  manifes- 
tations of  syphilis  and  cure  the  symptoms.  Among  these  the  different 
preparations  of  mercury  and  of  iodine  undoubtedly  hold  the  first  rank ;  but 
the  opponents  of  the  internal  use  of  mercury  claim  that,  by  curing  the 
earlier  symptoms,  the  disease  proper  is  only  being  suppressed,  that  its 
total  duration  is  thereby  prolonged,  and  its  later  symptoms  rendered  more 
obstinate  and  more  destructive.  This  assumption,  however,  is  the  result 
of  the  heat  of  controversy  more  than  of  any  calm  recognition  of  facts. 

Who  shall  say,  in  a  given  case,  how  long  syphilis  is  to  last?  There 
is  no  certain  and  reliable  standard  by  which  the  disease  may  be  judged 
or  the  quality  of  its  virulence  predicated.  There  is  an  unknown  element 
in  syphilis  which  alone  can  explain  the  endless  irregularity  of  its  forms 
and  the  picturesque  variety  of  its  symptoms. 

One  fact  about  syphilis  is  well  known ;  it  has  symptoms,  and  certain 
drugs  will  keep  down  those  symptoms ;  and  it  is  as  wise  and  as  just  to 
say  that  the  quinine  which  breaks  tertian  ague  only  prolongs  the  disease 
by  suppressing  the  symptoms,  as  it  is  to  hold  that  mercury  prolongs 
syphilis  by  keeping  symptoms  in  check. 

Moreover,  the  use  of  mercury  has  been  shamefully  abused  in  times 
past.  Crusades  have  been  preached  against  it  by  valiant  champions  of 
other  and  seemingly  more  simple  methods,  yet  always,  century  after  cen- 
tury, the  profession  clings  to  mercury ;  and  to-day  it  heads  the  list  of 
specifics,  as  being  the  most  efficieHt  of  all  known  drugs,  in  the  writings 
of  a  great  majority  of  the  recognized  authorities  upon  syphilis.  The  only 
question  is  how  to  use  mercury  so  that  it  shall  inflict  the  greatest  possible 
harm  upon  the  disease  without  injuring  the  patient.  A  solution  of  this 


THE   GENERAL  TREATMENT   OF   SYPHILIS.  225 

problem  is  what  is  required.  The  senior  author  has  done  what  he  could 
toward  solving  it. 

All  sorts  and  varieties  of  other  drugs — copper,  gold,  arsenic,  sarsa- 
parilla,  and  various  vegetable  so-called  blood  purifiers — have  been  and 
are  to-day  vaunted  as  possessing  curative  powers  over  syphilis,  as  have 
also  the  waters  of  numberless  natural  mineral  springs;  but  no  two 
authorities  agree  in  defining  the  claims  of  these  adjuvants  to  treatment, 
while  all  advocate  mercury  administered  in  one  way  or  another. 

Finally,  all  sorts  of  cures  have  been  tested :  water  cures,  dry  cures, 
sweating  cures;  cures  by  the  grace  of  God  (Diday) — that  is,  where  noth- 
ing is  done  in  mild  cases  beyond  what  is  suggested  by  ordinary  hygiene, 
the  disease  being  left  to  run  itself  out  by  nature ;  cures  by  syphilization 
and  by  tartarization ;  and  finally,  by  drugs,  cathartics,  diuretics,  sudori- 
fics,  tonics,  mercury,  iodine,  etc. 

When  so  many  methods  are  strongly  advocated,  it  seems  fair  to  sup- 
pose that  the  disease  in  question  is  incurable;  but,  on  the  contrary,  pa- 
tients get  well,  or  seemingly  well,  under  all  these  methods  and  under 
all  systems  of  treatment.  The  reason  of  this  seems  to  be  that  the  dis- 
ease is  self-limiting  and  symptoms  cease  to  appear,  in  a  majority  of 
cases,  in  the  long  run,  with  treatment,  without  treatment,  sometimes 
despite  treatment. 

The  aim  of  a  rational  treatment,  therefore,  must  be:  to  suppress 
symptoms  and  prevent  them  from  doing  harm  during  their  existence ;  to 
control  symptoms  and  prevent  relapse  without  harming  the  patient ;  and 
so  to  manage  the  disease  that  it  may  not  be  contagious  during  its  exist- 
ence (by  keeping  down  such  symptoms  as  yield  contagious  secretions), 
that  the  patient  may  be  made  able  to  marry  as  soon  as  possible  and  to 
produce  healthy  offspring,  and  that  the  symptoms  of  the  disease  during 
their  progress  shall  be  restrained  from  leaving  unsightly  scars  or  damag- 
ing the  structure  of  tissues  or  organs. 

These  ends  may  be  more  certainly  attained  by  the  judicious  use  of  the 
preparations  of  mercury  and  iodine  than  by  any  other  means ;  and  this 
is  the  reason  why  these  drugs  hold  their  place  in  medicine  as  antisyphi- 
litic  specifics,  notwithstanding  the  fact  that  the  disease  goes  on  and  runs 
its  full  course  in  spite  of  their  use,  and  notwithstanding  the  fact  that 
much  harm  has  doubtless  been  done  with  the  drugs  by  their  unskilful  use. 

Sigmund  and  Diday  about  twenty  years  ago  made  strong  pleas  for 
what  might  be  called  the  hygienic  and  expectant  treatment  of  syphilis 
when  mild,  believing  that  mercury  did  harm  in  such  cases  and  that  nature 
might  be  safely  trusted  to  cope  with  them ;  yet  even  they  in  all  severe 
cases  founded  their  hopes  upon  mercury  alone. 

Zeissl, '  in  a  studied  essay,  states  that  by  observing  the  evolution  of 

1  Wiener  med.  Zeitung,  Xos.  1,  2,  3,  and  4,  1879. 

15 


226  VENEREAL   DISEASES. 

syphilis  under  the  expectant  treatment,  he  learned  that  the  malady  was 
atypical,  seeming  to  depend,  for  the  length  of  time  it  lasted  and  the 
severity  of  its  symptoms,  more  upon  the  personal  physical  individuality 
of  the  patient  than  upon  the  treatment  to  which  he  was  subjected.  And 
there  is  a  large  measure  of  truth  in  this  conclusion,  and  because  of  it  a 
skilful  advocate  may  justify  all  heresies  of  treatment  and  with  equal  ease 
condemn  the  most  sound  doctrine. 

Some  of  the  symptoms  of  syphilis  disappear  under  the  influence  of 
intercurrent  disorders.  Thus,  Mauriac  has  shown1  that  erysipelas  exer- 
cises a  curative  influence  over  the  cutaneous  manifestations  of  syphilis. 
The  eruption  fades,  that  part  over  which  the  erysipelas  has  travelled 
getting  well  promptly,  while  the  more  distant  lesions  are  slower  in 
disappearing. 

This  is  not  more  strange  than  the  disappearance  of  cutaneous  lesions 
not  syphilitic,  on  the  advent  of  some  internal  malady — tuberculous 
meningitis,  typhoid  fever,  and  others. 

The  Hot  Springs  of  Arkansas. — These  springs  have  acquired  a  wide- 
spread popularity,  and  some  estimate  of  their  value  must  be  given.  Some 
of  the  best  physicians  at  the  .Springs  state  in  so  many  words  that  there 
is  no  more  virtue  in  that  hot  water  than  in  other  water  equally  heated. 
The  water  is  very  hot,  so  that  it  has  to  be  reduced  before  patients  can 
use  it  for  drinking  or  bathing  purposes.  It  is  a  clear,  pure  water,  prac- 
tically devoid  of  minerals,  and  is  used  upon  some  of  the  hotel  tables, 
cold  of  course,  as  ordinary  drinking-water.  It  is  not  exported,  no  one 
for  a  moment  believing  that  the  water,  when  cold,  possesses  any  medicinal 
virtue  whatsoever.  Yet  there  is  something  about  the  heat  that  differs 
from  the  heat  imparted  to  ordinary  water  by  boiling  it.  Thus  a  bath 
taken  in  the  spring  water  reduced  to  98°  F.  will  make  the  perspiration 
roll  in  drops  from  one's  nose  while  lying  in  the  bath — a  phenomenon 
which  will  not  occur  when  he  takes  a  bath  at  98°  F.  in  his  own  bath-tub 
at  home.  Moreover,  one  may  raise  the  temperature  of  the  entire  body  (as 
shown  by  a  thermometer  in  the  mouth)  by  taking  a  foot-bath  in  Hot 
Springs'  water;  and  he  will  fail  to  do  this  while  taking  a  more  prolonged 
foot-bath  in  much  hotter  water  at  home.  The  diuretic  and  diaphoretic 
qualities  of  the  Hot  Springs'  water  are  also  most  marked — qualities  both 
of  which  are  lost  when  the  water  is  allowed  to  cool.  Furthermore,  it  is 
notorious  and  most  obvious  that  one  may  absorb  a  vastly  greater  amount 
of  mercury  by  inunction,  the  prevailing  method  at  the  Springs,  than  at 
home  without  inducing  salivation;  and  even  more  strikingly  a  patient  who 
at  home,  let  him  drink  any  amount  of  ordinary  hot  water,  will  revolt  at 
three  hundred  grains  of  iodide  of  potassium  a  day  and  fail  to  find  relief 

4  "Etude  clinique  sur  1'Influence  curative  tie  1'Erysipele  dans  la  Syphilis." 
Paris,  1873. 


THE    GENERAL    TREATMENT   OF   SYPHILIS.  227 

from  his  severe  tertiary  symptoms,  at  the  Springs,  while  drinking  freely 
and  bathing  in  the  natural  hot  water,  will  digest  one  thousand  grains  a 
day  with  hardly  a  murmur,  and  consequently  will  see  his  symptoms 
promptly  disappear. 

It  is  this  quality  that  gives  value  to  the  Hot  Springs — a  value  which 
they  certainly  have. 

A  patient  with  chancre  and  early  syphilis  is  no  better  off  at  the  Hot 
Springs  than  he  is  anywhere  else.  He  is  rather  worse  off,  because  he  is 
liable  to  be  overtreated  and  to  be  deluded  into  a  false  security  because 
his  symptoms  disappear  quickly.  His  relapses  occur  just  the  same,  and 
his  malady  lasts  exactly  as  long  whether  he  goes  to  the  Hot  Springs  or 
not.  He  gains  nothing.  His  treatment  can  be  carried  on  just  as  well 
at  home,  and  he  avoids  exposure  to  publicity  and  public  criticism,  by 
staying  at  home. 

It  is  only  in  the  cachectic  and  in  those  whose  tolerance  of  mercury  is 
poor,  or  whose  stomachs  refuse  to  absorb  enough  iodide  of  potassium 
promptly  to  control  their  gummatous  lesion — it  is  only  in  these  cases  that 
the  Hot  Springs  lend  valuable  aid,  and  in  such  cases  the  aid  is  most  valu- 
able— so  valuable  that  it  would  be  a  serious  loss  to  the  community  were 
the  Hot  Springs  to  disappear  from  the  face  of  the  earth. 

This  same  quality — namely,  uot  directly  affecting  syphilis  in  the 
very  minutest  degree,  but  making  the  patient  vastly  more  tolerant  of 
mercury  and  iodide  of  potassium,  which  latter  do  the  work — this  same 
quality  is  possessed  more  or  less  by  all  hot  springs  having  marked  diu- 
retic and  diaphoretic  properties  whatever  be  their  mineral  constitution 
—and  by  the  cave  at  Glenwood  Springs  as  well — they  greatly  aid  the 
patients  to  take  mercury  and  iodide  of  potassium  freely,  an  aid  which 
has  to  be  invoked  for  emergencies,  but  for  emergencies  only.  No  natural 
spring  so  far  as  heard  from  has  any  specific  influence  over  the  manifes- 
tations of  syphilis,  except  locally  to  stimulate  the  granulation  of  chronic 
ulcers. 

Hygienic  Treatment. — The  hygienic  surroundings  of  a  patient  influ- 
ence his  general  health,  and  upon  the  maintenance  of  good  general  health 
often  depends  the  quality  of  the  syphilitic  symptoms  in  a  given  case. 
This  remark  is  not  absolutely  true — indeed,  probably  no  remark  made 
about  syphilis  is  absolutely  true.  Some  old  men,  with  broken  vitality, 
in  the  decline  of  life,  get  syphilis,  and  have  it  in  the  very  mildest  form, 
while  robust  youths  sometimes  sink  away  promptly  under  a  malignant 
onset  of  the  disease.  The  activity  of  the  poison  in  babyhood  is  well 
known,  and  that,  too,  not  in  cases  of  inherited  syphilis  alone.  Epidemics 
of  vaccinal  syphilis  clearly  prove  the  virulence  of  acquired  syphilis  in  the 
infant.  Therein  there  are  apparently  certain  diathetic  or  constitutional 
peculiarities  of  the  individual  which  influence  the  quality  of  his  syphi- 
litic symptoms,  and  act  independently  of  hygienic  surroundings  and  of 


228  VENEREAL  DISEASES. 

everything  else.  This  subject  has  been  discussed  in  the  section  on  Prog- 
nosis. 

Therefore  it  cannot  be  absolutely  said  that  hygiene,  when  good,  will 
make  syphilis  mild,  and  when  bad,  will  make  it  severe,  for  this  is  not  the 
case.  It  is  possible,  however,  I  think,  to  make  the  following  assertion 
with  truth :  that,  other  things  being  equal,  the  better  the  hygiene  and 
dietetics  the  more  creditably  will  the  patient  weather  the  storm,  and  the 
more  certainly  will  his  disease  get  well  without  materially  damaging  him. 
This  assertion,  of  course,  implies  that,  in  addition  to  his  hygiene  and 
dietetics,  the  patient  shall  make  use  of  intelligent  therapeutics. 

The  hygiene  of  syphilis  is  that  of  common,  every-day  life.  We  no 
longer  confine  patients  to  their  beds  for  the  treatment  of  syphilis,  or  even 
to  the  house.  The  old  notion,  that  it  is  such  a  serious  matter  for  a  pa- 
tient taking  mercury  to  catch  cold,  cannot  be  held  in  force.  Surely  it  is 
wiser  for  a  patient  taking  mercury  not  to  catch  cold,  because  the  cold  is 
likely  to  upset  his  stomach  and  to  interfere  with  his  treatment;  but 
beyond  this  nothing  is  likely  to  happen,  nor  is  it  at  all  probable  that  a 
patient  taking  mercury  in  a  mild,  continuous  way  is  any  more  likely  to 
catch  cold  upon  exposure  than  another  under  the  same  circumstances  not 
taking  mercury.  Mercury  may  open  the  pores,  as  the  popular  notion  is, 
for  all  that  is  known  to  the  contrary.  Mercury  certainly  is  excreted  in 
minute  amounts  by  the  skin,  in  the  perspiration ;  but  it  means  nothing  to 
say  that  the  pores  are  open — they  undoubtedly  always  are  open.  Finally, 
to  sum  up,  it  may  be  confidently  stated  that  a  patient,  while  taking  a  mild, 
continuous  course  of  mercury,  may  go  out  in  the  cold,  the  rain,  and  the 
storm,  exactly  in  the  same  way  as  if  he  were  not  taking  the  drug,  without 
being  injured  thereby. 

Moreover,  a  cold  taken  in  the  active  stage  of  syphilis  may  produce 
sore  throat,  and  this  sore  throat,  due  primarily  to  cold,  may  be  the  occa- 
sion of  a  local  outcrop  of  mucous  patches  and  syphilitic  ulcers  in  the 
throat,  which  may  continue  long  and  greatly  annoy  the  patient,  as  well 
as  possibly  aggravate  his  disease  by  interfering  with  swallowing,  and 
therefore  with  nutrition.  An  accidental  sore  throat  may  produce  syphi- 
litic symptoms  in  the  throat  just  as  smoking  may,  and  just  as  a  blister 
placed  upon  the  skin,  or  a  sulphur  bath,  may  call  out  a  syphilitic  eruption 
upon  a  patient  whose  skin  until  then  has  remained  clear. 

Probably  the  best  precautions  against  taking  cold  are  the  use  of 
coarse  bath  mittens  every  morning  upon  the  dry  skin  of  the  whole  body, 
when  there  is  no  general  eruption;  soaking  the  feet,  upon  retiring  at 
night,  in  cold  water,  washing  the  neck  and  chest  in  cold  water  in  the 
morning,  and  not  wrapping  up  the  throat  tightly  while  out  of  doors— as 
well  as  the  avoidance  of  wet  feet  and  draughts. 

Cleanliness  of  the  whole  surface  of  the  body  by  frequent  bathing  is 
very  desirable  during  the  whole  continuance  of  the  treatment.  Of  exer- 


THE    GENERAL   TREATMENT    OF   SYPHILIS.  229 

else  and  air  the  patient  should  have  an  abundance.  The  function  of  the 
stomach  and  the  intestine  should  be  ministered  to  by  appropriate  food, 
and  regularity  as  strict  as  possible  should  be  observed  in  regard  to  meal- 
times and  the  hours  of  sleep. 

As  to  the  kind  of  food  to  be  used,  no  special  restrictions  need  be  put 
upon  the  patient.  He  may  eat  what  he  chooses  and  what  he  knows  will 
agree  with  him  in  full  quantity,  in  ordinary  health.  There  is  no  objec- 
tion to  the  use  of  wine  or  beer  in  moderation  with  the  meals,  but  any  ex- 
cess in  alcohol  in  any  shape  is  harmful,  and  drinking  between  meals 
should  not  be  allowed.  Many  individuals  do  very  much  better  if  they  ob- 
serve total  abstinence.  Acids  are  considered  harmful  when  mercury  is 
being  actively  pushed — but  only  in  such  cases.  When  taking  an  ordinary 
mild,  continuous  course  a  patient  may  eat  pickles  and  acid  fruits — lemons 
— in  all  ordinary  amounts  without  discomfort  or  disadvantage.  When  a 
patient  is  being  crowded  with  mercury,  acids  may  encourage  salivation. 

Under  certain  circumstances  the  regulation  of  food  becomes  very  im- 
portant, namely,  when  the  medicine  irritates  the  stomach  so  that  it  cannot 
be  borne.  The  mercurials  in  any  form,  in  some  cases  of  weak  digestion 
and  irritable  bowels,  cause  more  or  less  griping  and  colicky  pain,  and  the 
iodides  often  produce  nausea  and  disability  of  the  stomach.  The  mercury 
may  be  made  to  remain  quietly  in  the  intestine  by  the  aid  of  opium,  but 
it  is  far  better  to  accomplish  the  same  result,  if  possible,  by  means  of  a 
change  of  food. 

When,  therefore,  moderate  medication,  such  as  may  be  necessary  to 
keep  down  the  symptoms,  is  found  to  produce  pain  and  diarrhoea,  all 
fruit  and  green  vegetables  must  be  denied  the  patient.  He  should  take 
but  little  fluid  of  any  sort.  He  should  eat  stale  bread,  tender  meat,  rice 
and  boiled  milk,  eggs  and  toast,  and  by  the  exercise  of  these  simple  pre- 
cautions he  will  often  be  able  to  continue  his  mercury  and  avoid  opium. 
If  another  medicine  must  be  given,  it  is  well  to  commence  with  gr.  x.  doses 
of  the  subnitrate  of  bismuth;  and  if  this  serves  to  comfort  the  intestine, 
and  keep  pain  and  diarrhoea  in  check,  it  certainly  is  simpler  and  less  apt 
to  do  harm  than  opium.  The  digestive  disturbance  will  sometimes  dis- 
appear when  the  form  in  which  the  mercury  is  administered  is  changed. 
Besides  these  means,  it  may  sometimes  be  necessary  to  employ  opium  as 
well;  but,  if  the  opium  can  be  avoided,  it  is  to  the  patient's  advantage. 

The  same  general  precaution  in  regard  to  diet  may  be  employed  when 
the  iodides  disagree.  The  subcarbonate  of  bismuth  may  be  tried  instead 
of  the  subnitrate  in  these  cases. 

The  residence  of  the  patient  is  not  a  matter  of  much  importance,  if 
his  general  health  and  his  appetite  remain  fair,  and  his  symptoms  yield 
reasonable  obedience  to  the  medicines  employed.  Change  of  air,  how- 
ever, is  always  desirable  occasionally,  even  for  persons  in  ordinary  good 
health,  and  this  is  the  more  necessary  when  the  patient  is  laboring  under 


230  VENEREAL  DISEASES. 

a  devitalizing  disease.  Therefore,  even  if  the  course  of  the  malady  leaves 
nothing  to  be  wished  for,  it  is  wise,  for  such  patients  as  can  afford  the 
time  and  the  money,  to  make  a  change  of  residence  for  a  certain  period 
of  time  each  year,  in  the  summer  if  they  live  in  town,  in  the  winter  if 
their  home  be  rural. 

This  change  of  air  and  surroundings  becomes  a  matter  of  necessity  in 
some  cases,  particularly  in  the  later  periods  of  the  disease,  if  there  be  any 
tendency  to  cachexia.  I  have  known  patients,  both  early  and  late  in  the 
disease,  who  have  failed  to  respond  to  medication  until  that  medication 
has  been  supplemented  by  a  change  of  air,  when  not  only  would  the 
symptoms  promptly  mend,  but  the  tone  of  the  stomach  would,  improve, 
and  medicines  which  could  not  be  taken  at  all  without  interfering  with 
digestion  could  be  borne  .without  a  murmur.  This  is  particularly  the  case 
with  the  iodides. 

In  one  case  in  mind  this  effect  was  strongly  marked.  The  patient  had 
a  node  which  threatened  to  destroy  the  nasal  bones.  He  could  not  take 
the  iodides  without  having  his  stomach  totally  upset,  while  at  the  same 
time  the  iodides  produced  a  brilliant  crop  of  purpura  on  each  occasion 
when  they  were  tried.  The  patient  was  therefore  sent  to  the  country, 
with  directions  to  continue  his  medicines  there.  A  few  days  sufficed. 
He  bore  the  drug  well,  his  purpura  disappeared,  his  stomach  regained 
its  tone,  the  node  in  his  nose  visibly  diminished  in  size.  He  returned 
to  the  city,  thinking  himself  safe ;  but  a  few  days  convinced  him  to  the 
contrary :  his  stomach  again  refused  food,  his  purpura  returned,  and  he 
was  obliged  to  go  back  to  the  country  and  to  remain  there  until  his  node 
disappeared,  which  it  promptly  did. 

The  advantage  patients  in  the  cachectic  stage  of  syphilis  often  derive 
from  visits  to  springs,  or  to  cities  even,  for  the  purpose  of  consulting  some 
special  physician  about  their  disease,  is  no  doubt  sometimes  due  to  the 
improved  hygienic  effect  of  their  surroundings.  This  effect  in  New  York 
City  seems  to  last  about  six  weeks,  after  which  patients  become  used  to 
the  locality  and  fail  any  longer  to  improve  in  it — from  the  effect  of  cli- 
mate alone. 

The  hygiene  of  the  mouth  is  of  the  first  importance  in  the  treatment  of 
syphilis.  Mouth  lesions  and  throat  lesions  form  some  of  the  most  obsti- 
nate features  of  the  disease,  and  these  lesions  are  less  apt  to  be  severe 
when  the  mouth  is  kept  clean  and  free  from  the  contact  of  irritants. 
At  the  very  beginning  of  syphilis,  therefore,  before  the  mercurial  course 
is  commenced,  the  patient  should  be  sent  to  a  dentist  to  have  his  teeth 
put  in  thorough  order.  All  the  tartar  should  be  carefully  scraped  away 
from  the  necks  of  the  teeth,  and  all  old  stumps  extracted,  and  sharp 
projecting  angles  of  teeth  likely  to  come  into  contact  with  the  tongue  filed 
off.  The  patient  should  be  instructed  that  he  will  do  well  to  visit  the 
dentist  regularly  every  six  months  if  the  tartar  tends  to  re-accumulate 


THE   GENERAL   TREATMENT   OF   SYPHILIS.  231 

quickly,  as  it  does  in  some  cases.  During  the  whole  of  the  treatment  a 
very  soft  tooth  brush  should  be  used,  for  the  stiff  bristles  of  a  hard  brush 
cut  and  injure  the  gums,  and  make  them  more  likely  to  become  irritated 
under  the  influence  of  mercury  than  if  a  soft  brush  be  used.  Any  tooth 
wash  employed,  or  tooth  powder,  should  be  strongly  alkaline  and  a  little 
astringent.  A  good,  simple  tooth  wash  is  made  by  putting  half  a  tea- 
spoonful  or  more  of  bicarbonate  of  soda  into  a  glass  of  water,  and  adding 
a  teaspoonful  of  tincture  of  myrrh.  Ordinary  white  castile  soap  makes  a 
good  and  simple  tooth  paste,  and  the  mouth  may  be  washed  out  afterward 
with  some  alum  and  water,  or  some  tincture  of  krameria  (  3  i. )  in  aqua 
gaultherise  (  §  iv.). 

Smoking  should  be  forbidden  when  mouth  lesions  persist  and  are 
troublesome.  In  some  the  mucous  membranes  are  but  little  if  at  all  in- 
volved, and  such  may  smoke  if  they  wish  to,  or  even  chew  tobacco  with 
impunity — it  is  totally  a  personal  question. 

A  pipe  is  a  dangerous  thing  for  a  patient  with  syphilis  to  use,  for  he 
runs  the  risk  of  infecting  any  friend  who  might  use  it,  the  secretions  of 
mucous  patches  and  syphilitic  ulcers  in  the  mouth  being  particularly  con- 
tagious. 

The  hygiene  of  the  genitals  and  of  the  anus  is  also  important.  These 
parts  in  both  sexes  should  be  kept  scrupulously  clean  and  dry,  otherwise 
mucous  patches  and  condylomata,  excoriations  and  ulcerations,  may  be 
looked  for.  Should  there  be  any  tendency  to  moisture  about  these  parts 
externally,  they  may  be  dusted  with  dry  powders,  talcum  powder  or  bis- 
muth, with  or  without  a  little  calomel,  after  proper  cleansing.  It  is 
well,  in  some  cases,  to  have  the  patient  wash  the  anus  with  soap  and 
water  after  each  action  of  the  bowels.  The  umbilicus,  also,  in  fat  peo- 
ple, and  the  skin  under  the  breasts  in  fat  women,  require  frequent  wash- 
ing, drying,  and  dusting  to  preserve  the  parts  in  good  condition  during 
the  eruptive  period. 

Medicines  used  in  syphilitic  cases,  to  keep  up  the  general  health  or 
regulate  the  functions,  come  more  justly  under  the  head  of  hygiene  than 
of  specific  medication. 

All  tonics  find  a  fair  field  for  their  exercise  in  syphilitic  subjects,  and 
do  good — not,  perhaps,  in  curing  the  disease,  but  by  holding  the  patient 
up  while  it  works  out  its  periods.  The  effect  of  mercury,  when  given  in 
small  doses  for  a  long  or  for  a  short  time,  is  undoubtedly  tonic,  as  has 
been  shown;1  but  it  is  not  at  all  on  account  of  this  tonic  action  that  mer- 
cury given  in  minute  doses  eliminates  the  syphilitic  poison.  Other  drugs 
are  far  more  tonic  in  their  action,  but,  having  no  specific  power  over  the 
symptoms  of  syphilis,  they  directly  modify  the  disease  but  little,  if  at 
all.  The  only  advantage  claimed  for  the  long-continued  use  of  mercury 

1  "The  Effect  of  Small  Doses  of  Mercury,"  etc.,  Am.  Journ.  Med.  Sci.,  January, 

1876. 


232  VENEREAL   DISEASES. 

in  minute  doses  is  that,  while  acting  in  minute  doses  as  a  specific,  it  has 
the  great  advantage  to  the  patient  of  being  at  the  same  time  tonic. 

Now,  the  ordinary  tonics — such  as  the  long  list  of  vegetable  bitters, 
the  quinine  group,  iron,  and  analogous  drugs,  together  with  cod-liver  oil 
and  similar  blood-formers — all  of  these  serve  a  good  part  in  the  treat- 
ment of  syphilis,  just  as  other  hygienic  means  do.  If  employed  with 
intelligence  and  judiciously  changed,  they  in  a  measure  take  the  place  of 
change  of  air  and  selection  of  food  in  those  cases  in  which  lack  of  money 
will  not  allow  the  patient  to  alter  his  food  or  to  get  a  change  of  air. 
Cod-liver  oil  is  a  particularly  useful  adjuvant  to  treatment  in  those  cases 
in  which  the  blood-making  powers  are  defective,  while  the  ability  to 
digest  fat  remains. 

In  persons  who  lack  blood,  yet  in  whom  the  stomach  refuses  to  accept 
or  to  assimilate  so  concentrated  a  food  as  cod-liver  oil,  an  excellent  substi- 
tute is  found  in  kumyss,  buttermilk,  zoolak,  matzoon. 

SPECIFIC  TREATMENT. 

The  specific  treatment  of  syphilis  is  a  treatment  of  the  disease  by 
those  drugs  which  are  known  commonly  to  control  the  symptoms  in  an 
immediate  manner.  These  drugs  are  the  preparations  of  mercury  and  of 
iodine.  The  latter  are  found  to  exercise  much  less  influence  over  the 
symptoms  of  early  syphilis  than  mercury  does ;  but,  they  possess  a  con- 
trolling power  over  many  of  the  later  manifestations  of  the  disease,  par- 
ticularly those  dependent  upon  gummatous  deposit,  no  matter  in  what 
tissue  such  deposit  occurs. 

Mercury,  on  the  other  hand,  has  undoubted  value  in  all  stages  of 
syphilis  and  over  all  its  lesions,  but  less  control  over  gummatous  deposit 
than  over  other  lesions.  While  sometimes  it  will  (in  form  of  fumigation) 
influence  a  gummatous  lesion  (ulcer,  for  example)  more  positively  and 
more  promptly  than  the  iodides,  yet,  as  a  rule,  it  cannot  be  relied  upon 
for  this  purpose.  The  iodides,  in  such  cases,  serve  an  excellent  part  to 
supplement  the  action  of  mercury.  In  treating  a  gumma,  the  object  is 
to  dissipate  the  deposit  as  promptly  as  possible,  so  as  to  save  the  tissues 
involved  from  damage  by  pressure,  or  by  disintegration  when  they  are  in- 
cluded in  the  gummatous  mass ;  and  this  the  iodides  do  speedily  if  vig- 
orously pushed  and  well  borne  by  the  stomach,  while  the  mercurials  will 
often  fail  to  do  it. 

The  iodides,  on  the  other  hand,  have  little  or  no  power  to  prevent 
relapse ;  and,  when  they  have  done  all  their  work,  mercury  often  has  to 
be  called  in  to  clinch  the  cure,  and  to  prevent  a  return  of  the  symptoms. 
Thus  the  two  specifics  support  each  other. 

The  senior  author  has  demonstrated  in  two  essays1  that  the  red  cells  of 

1 "  Effect  of  Small  Doses  of  Mercury, "etc.,  Am.  Journ.  of  the  Med.  Sci.,  January, 
1876,  and  "The  Treatment  of  Syphilis,"  Philadelphia  Med.  Congress,  1876. 


THE   GENERAL,   TREATMENT   OF   SYPHILIS.  233 

the  blood  are  increased  in  number  when  mercury  is  used  continuously  in 
a  certain  way.  Hence  it  is  a  tonic  when  so  used,  in  spite  of  the  protest 
from  Germany  that  it  does  not  act  (as  to  the  elimination  of  urea,  the  bod- 
ily temperature,  etc.)  just  like  iron,  and  in  spite  of  the  protest  from 
New  York  that  the  haemoglobin  should  have  been  quantitatively  esti- 
mated also.  Those  interested  in  following  the  study  of  the  blood  and 
the  course  of  argument  derived  from  other  facts  which  prove  that  mercury 
in  minute  doses  long  continued  is  a  tonic,  while  in  large  doses  it  is  atonic, 
diminishing  the  number  of  the  red  cells  in  the  -blood,  are  referred  to  the 
two  papers  in  question.  There  it  will  be  found  to  be  demonstrated  that 
mercury,  properly  used  for  a  number  of  years  in  succession,  cannot  do  any 
harm  to  a  patient,  while  it  certainly  in  most  cases  controls  his  symp- 
toms in  a  greater  or  less  degree.  The  years  which  have  passed  since  the 
appearance  of  those  papers  have  only  served  to  strengthen  the  convictions 
as  to  the  correctness  of  the  conclusions  there  reached.  The  only  modifi- 
cation made  has  been  to  increase  somewhat  the  dose  of  mercury  for  con- 
tinuous use. 

Mouth  symptoms  during  this  course  are  generally  more  obstinate  than 
any  others,  but  the  little  scaly  patches  upon  the  tongue  and  lips  may 
often  be  looked  upon  more  as  an  evidence  of  local  irritation  in  a  person 
once  syphilitic  than  anything  else,  and  may  often  be  succesfully  treated 
locally  without  making  any  change  in  the  internal  dose  which  the  patient 
may  be  taking  at  the  time. 

The  coup-sur-coup  plan  of  giving  mercury  is  unsatisfactory,  judged  by 
the  results  in  the  way  of  relapses  seen  in  patients  who  have  so  taken  the 
drug  at  competent  hands.  The  plan  known  as  Fournier's  treatment, 
which  consists  in  the  interrupted  use  of  mercury  in  mild  dose  (a  gentle 
coup-sur-coup  method),  with  stated  definite  intervals  in  which  no  treat- 
ment is  used,  seems  to  rest  upon  no  foundation  stronger  than  theory, 
since  syphilis,  a  malady  of  interruptions  undoubtedly,  has  its  interruptions 
at  indefinite  and  irregular  intervals.  Notwithstanding  that  intervals  of 
latency  in  the  malady  exist,  periods  of  apparent  immunity  from  the  dis- 
ease, yet  there  is  nothing  to  prove  that  the  patient  is  free  from  the  poi- 
-son  during  those  intervals,  but  everything  to  show  that  he  is  still  suffer- 
ing. The  cauterisatio  provocatoria  of  Tarnowsky  is  founded  upon  this 
assumption.  A  blister  or  a  local  irritant  (vaccination)  will  sometimes 
make  latent  syphilis  active — a  woman  seemingly  perfectly  healthy  will 
often  produce  a  syphilitic  child.  What  conclusion  can  therefore  be 
reached  except  that  syphilis  is  a  mild,  continuous  disease,  with  periods  of 
passive  latency  and  period  of  active  outbreak ;  and  what  treatment,  there- 
fore, recommends  itself  more  to  common  sense  than  a  mild,  long-continued, 
uninterrupted  treatment  by  a  specific  known  to  have  power  over  the  symp- 
toms, with  an  increase  in  the  quantity  of  that  specific  during  the  periods 
of  outbreak? 


234  VENEREAL   DISEASES. 

And  this  becomes  especially  apparent  when  it  can  be  shown,  as  has 
been  done,  that  the  continuous  use  of  the  mild  specific  acts  as  a  general 
tonic  (as  well  as  performing  its  work  as  a  specific)  during  the  whole 
period  of  its  administration. 

The  method  indeed  has  all  the  advantage  of  the  coup-sur-coup  meth- 
od, but  its  coup  is  mild.  It  hurts  only  the  disease,  never  the  patient. 
The  "  blow  "  falls  only  during  the  period  of  active  outbreak  of  the  dis- 
ease, while  the  general  treatment  has  the  further  advantage  of  acting  con- 
tinuously as  a  specific  in  eliminating  the  poison  of  syphilis  and  prevent- 
ing it  from  causing  outbreaks  in  the  way  of  serious  symptoms.  This 
treatment  constantly  tends  to  keep  the  disease  down,  and  to  keep  the 
patient  up.  It  does  not  cure  the  disease  so  much  as  it  conducts  the 
patient  safely  through  the  periods  of  the  disease.  It  does  not  prevent 
relapse  later  in  life  with  certainty,  for  occasional  cases  of  such  relapse  do 
certainly  occur ;  but  it  insures  one  more  positively  against  relapse  than 
any  other  form  of  treatment — at  least,  than  any  other  with  which  the 
authors  are  familiar. 

Salivation  is  undoubtedly  harmful.  Much  of  the  odium  which  rests 
upon  mercury  is  due  to  the  harm  it  has  done  to  the  mouths  and  stomachs 
of  patients  by  salivation.  In  the  days  when  it  was  considered  that  the  pa- 
tient never  had  arrived  at  his  proper  dose  of  mercury  until  he  was  caused 
to  spit  at  least  a  pint  in  twenty-four  hours,  how  much  damage  must  have 
been  done,  and  how  justly  has  mercury  paid  the  penalty  by  falling  into 
popular  disrepute! 

That  salivation  becomes  necessary  in  desperate  conditions  of  disease 
late  in  syphilis  is  certain;  but  surely  it  has  no  value  as  a  means  of 
general  treatment,  and  can  never  happen  to  a  patient  early  in  the  disease 
without  doing  him  positive  harm. 

The  time  when  the  general  treatment  of  syphilis  shall  be  commenced 
is  a  question  of  great  importance.  Unquestionably  it  should  be  com- 
menced as  soon  as  the  disease  is  diagnosticated;  but  the  difficulty  is  that 
diagnosis,  before  the  eruptive  stage — positively  absolute  diagnosis — is 
rarely  possible  without  confrontation,  and  even  then  there  is  a  chance  for 
error  found  in  the  possibility  of  infection  through  another  source,  or  in 
mediate  contagion. 

Practically,  therefore,  the  treatment  should  not  be  commenced  until 
the  first  general  symptoms  of  syphilis  appear ;  the  chancre  with  the 
accompanying  glandular  engorgement  is  not  enough  to  go  by.  If  treat- 
ment be  commenced  while  any  doubt  exists,  that  doubt  remains,  and  the 
patient  may  continue  in  doubt  for  the  rest  of  his  life,  to  his  great  discom- 
fort ;  therefore,  although  he  may  demand  treatment,  and  beg  for  it  when 
he  has  a  chancre,  the  surgeon  will  do  him  a  kindness  by  refusing  internal 
specific  measures  until  the  first  general  symptoms  begin  to  appear. 

In  the  rare  cases  in  which  diagnosis  can  be  positively  made,  without 


THE  GENERAL  TREATMENT  OF  SYPHILIS.          235 

the  chance  for  the  least  possible  doubt — as,  for  instance,  when  a  husband 
poisons  his  wife  or  his  child — treatment  may  and  should  be  commenced 
at  once  without  waiting  for  general  symptoms;  otherwise  it  is  safer  for 
all  parties  to  wait.  The  patient's  mind  may  be  satisfied,  meantime,  by 
cutting  out  his  chancre,  and  he  may  be  medicated,  to  his  advantage  doubt- 
less, with  tonics  of  all  kinds;  but  mercury  should  be  denied  him. 

Tonic  Treatment  by  Mercury. — The  method  about  to  be  described  is 
called  the  tonic  treatment  of  syphilis,  to  distinguish  it  from  other  meth- 
ods. It  is  tonic,  and  therefore  the  term  is  correct ;  but  it  does  not  cure 
syphilis  because  it  is  tonic.  It  cures  the  symptoms  because  it  is  a  spe- 
cific, and  the  tonic  action  is  only  an  accidental  one  found  to  attach  to  the 
method.  Even  if  it  were  not  tonic,  it  would  be  proper  to  use  mercury  in 
the  treatment  of  syphilis ;  and  indeed,  mercury  often  is  given,  and  prop- 
erly given,  in  such  a  way  as  to  be  a  specific  devoid  of  tonic  properties,  in 
that  it  is  used  in  large  doses — doses  which  have  been  shown  by  blood 
examinations  to  be  anything  but  tonic.  When,  however,  the  specific 
medicine  can  be  used  so  as  to  be  at  the  same  time  a  tonic,  a  step  in  ad- 
vance over  other  methods  is  taken,  and  that  is  the  reason  why  this 
method  is  called  the  "  tonic  treatment  of  syphilis." 

The  idea  of  this  treatment  is  best  carried  out  by  using  the  same  drug 
continuously  in  vaiying  doses.  If  the  preparation  has  to  be  changed  and 
great  accuracy  is  aimed  at,  it  is  necessary  to  make  a  new  set  of  tests  in 
order  to  find  the  tonic  dose.  The  preparation  which  we  have  used  the 
most  is  the  protoiodide  of  mercury  put  up  in  France  by  Garnier  et 
Lamoureux  in  the  form  of  sugar-coated  granules,  containing  exactly  1 
cgm.  each  (i  of  a  grain).1  The  advantages  of  this  preparation  are 
that  it  does  not  change  by  climate;  the  protoiodide  remains  fresh 
inside  the  sugar  coating,  and  the  latter,  being  thin  over  the  small  gran- 
ules, always  dissolves  in  the  stomach  readily ;  the  preparation  is  a  solid 
one  and  easy  to  carry  around,  and  to  take  without  causing  comment. 
The  protoiodide  has  no  special  value  over  any  other  mercurial.  The 
yellow  iodide  may  be  used — except  that  it  is  hard  to  find  the  tonic  dose 
unless  tablets  of  gr.  -J-  -  -^,  or  smaller  are  used — because  the  pure  yel- 
low iodide  causes  colicky  pain  to  many  persons  even  in  very  small  dose. 

1  There  is  a  spurious  granule  sold  which  resembles  the  French  granule  outside, 
but  if  cut  open  discloses  a  nucleus  of  white  sugar,  which  the  true  granule  does  not 
possess.  This  spurious  article  is  a  little  stronger  than  the  imported.  It  seems  to 
contain  more  yellow  iodide  and  less  green.  The  true  granule  is  anything  but  a  pure 
drug.  It  contains  the  chemically  pure  yellow  protoiodide,  the  impure  green  iodide, 
specks  of  red  biniodide  and  globules  of  metallic  mercury  with  a  little  free  iodine 
under  the  sugar  coating.  It  is  not  because  the  granule  is  a  pure  article  that  it  is 
popular,  but  because  it  is  uniformly  impure,  at  least  so  its  effects  seem  to  prove,  and 
it  is  weak,  so  weak  that  some  patients  do  not  seem  to  feel  them  at  all — taking  them 
in  large  numbers  very  freely.  But  on  the  other  hand  they  rarely  salivate  and  do  not 
cause  much  abdominal  pain  and  they  are  not  dangerous  for  the  patient  to  handle. 


236  VENEREAL   DISEASES. 

Small  pills  of  the  tannate  of  mercury,  of  gray  powder,  of  blue  mass,  of 
bichloride  may  be  used  equally  well,  whichever  form  the  physician  is 
most  accustomed  to  handle — always  remembering  that  the  individual  pill 
or  pellet  must  be  a  minute  dose,  if  this  form  of  treatment  is  to  be  strictly 
carried  out.  If  the  gray  powder  (mercury  with  chalk)  is  chosen  a  tablet 
of  one-third  or  one-half  a  grain  should  be  used  in  finding  the  tonic  dose. 

The  blue  mass  pill  with  iron  is  a  good  one,  the  granule  being  made  up 
of  a  quarter  of  a  grain  each  of  mercurial  mass  and  of  dried  sulphate  of 
iron — until  the  full  dose  and  the  tonic  dose  shall  have  been  determined — 
or  the  bichloride  of  mercury  may  be  used  in  tincture  of  the  sesquichloride 
of  iron ;  the  dose  being  so  regulated  that  one-fiftieth,  or  perhaps  better, 
one-hundredth  part  of  a  grain  of  the  bichloride  shall  be  the  standard  dose 
until  the  tonic  dose  has  been  ascertained. 

In  short,  any  preparation  or  combination  of  mercury  may  be  used, 
provided  it  does  not  contain  opium,  the  addition  of  which  would  make  it 
impossible  to  decide  accurately  what  the  tonic  dose  is.  The  standard 
dose  must  be  a  minute  one. 

The  idea  that  the  newer  preparations  of  mercury  are  better  than  the 
old  cannot  be  maintained,  and  no  extra  assistance  is  to  be  expected  from 
such  novelties  as  the  carbolate  of  mercury,  the  thymolate,  the  benzoate, 
the  formamide,  the  glycocoll,  the  alanate,  and  their  kind. 

To  bring  a  patient  under  the  tonic  treatment,  if  there  be  time,  the 
following  is  the  best  course :  Let  him  take  one  standard  dose  of  mercurial 
(one  granule  of  the  protoiodide,  for  example)  after  each  meal  for  two  or 
three  days.  On  the  fourth  day  one  extra  standard  dose  is  added  at 
the  midday  meal;  now  four  standard  doses  (granules)  are  taken  daily, 
and  this  is  to  be  continued  for  three  days. 

On  the  succeeding  fourth  day  another  standard  dose  is  added,  the  five 
daily  standard  doses  being  taken  two  in  the  morning,  one  at  noon,  and 
two  at  night.  On  the  next  following  fourth  day,  always  counting  from 
the  last  fourth  day,  another  dose  is  added,  two  standard  doses  being  now 
taken  after  each  meal — six  (granules)  a  day. 

In  this  way  the  amount  of  mercurial  given  is  gradually  increased, 
while  the  patient  uses  bland  food  in  moderate  quantity  and  regulates  his 
habits  aa  far  as  may  be,  and  the  dose  is  slowly  increased  every  third  or 
fourth  day,  or  even  every  second  day,  if  the  patient  be  pushed  for  time 
and  the  presence  of  an  eruption  makes  haste  an  object,  until  the  irritat- 
ing or  the  poisonous  action  of  the  drug  begins  to  manifest  itself. 

If  in  any  given  case  the  symptoms  are  so  pressing  that  there  is  not 
time  to  get  the  patient  quietly  under  this  treatment,  there  is  no  objection 
to  treating  him  by  any  of  the  older  methods  until  his  symptoms  abate. 
He  may  be  rapidly  brought  under  the  mild  influence  of  mercury  until  the 
drug  shows  faintly  along  the  edge  of  the  gums,  either  by  inunction,  by 
daily  fumigations,  or  by  corrosive  chloride  in  tincture  of  bark,  taken 


THE    GENERAL   TREATMENT   OF   SYPHILIS.  237 

diluted,  after  meals;  and  when  finally  the  urgent  symptom  has  fairly 
declined,  all  medication  may  be  suspended  for  a  week  or  more,  and  then 
uuder  less  pressure  the  mercurial  course  may  be  instituted  as  directed 
above. 

One  advantage  of  the  French  protoiodide  granules,  which  was  not 
alluded  to  above  in  the  list  of  its  virtues,  is  that,  although  it  does  not 
gripe  when  given  in  small  quantities,  yet  it  does  show  its  irritating 
effects,  usually  upon  the  intestine,  before  it  produces  any  trouble  in  the 
mouth.  This  is  not  always  the  case,  but  it  is  the  rule;  consequently, 
during  this  course  of  granules,  diarrhoea  and  griping  pain  are  to  be 
watched  for.  A  slight  looseness  of  the  bowels  is  unimportant.  Such  a 
looseness  often  comes  on  during  the  early  days  of  the  course;  but,  by 
holding  the  drug  at  the  same  dose,  it  subsides,  and  then  the  doses  may 
be  increased  as  before. 

When  a  dose  of  six  to  nine,  or  even  twelve  granules  a  day  in  some 
cases,  has  been  reached,  it  will  produce  a  very  positive  attack  of  diar- 
rhoea, with  pain  in  the  intestines ;  and  occasionally  at  the  same  time  the 
breath  will  begin  to  have  the  mercurial  fetor,  and  the  livid  line  will 
begin  to  show  faintly  along  the  edge  of  the  gums  at 'the  necks  of  the 
teeth,  while  the  teeth  themselves  become  a  little  sensitive  on  being 
snapped  sharply  together,  and  the  saliva  flows  more  freely.  These  latter 
symptoms  are  generally  not  much  marked  with  the  protoiodide,  and  they 
may  be  absent  entirely  while  the  griping  and  diarrhoea  are  quite  positive, 
and  this  feature  is  an  advantage  in  favor  of  the  protoiodide. 

When  either  of  these  sets  of  symptoms  occurs,  the  patient  has  reached 
his  limit.  He  is  taking  what  is  called  his  "  full  dose  " — a  dose  which  he 
may  continue  to  take  with  the  aid  of  selected  food  and  a  little  opium,  and 
may  indeed,  in  most  cases,  continue  to  take  without  becoming  salivated. 
This  dose  is  anything  but  tonic.  If  it  be  continued,  the  patient  surely 
suffers  in  time,  both  in  the  stomach  and  in  the  quality  of  his  blood,  while 
his  strength  and  physical  powers  are  diminished  by  it.  This  "  full  dose," 
therefore,  is  to  be  used  only  in  case  of  necessity.  It  is  specific,  and  pos- 
sesses fully  the  antagonistic  influence  to  syphilis  which  the  mercurials 
enjoy;  and  the  patient  may  take  this  dose  for  a  considerable  period  with- 
out injury,  if  his  symptoms  require  it,  with  the  aid  of  a  little  opium  to 
give  him  comfort,  or  preferably  without  opium,  by  changing  his  food, 
drinking  boiled  milk,  and  eating  rice. 

This  "full  dose,"  the  size  of  which  varies  greatly  in  different  individ- 
uals, may  be  maintained  until  the  activity  of  any  existing  symptoms 
declines,  and  then  it  should  be  dropped  and  the  "  tonic  dose  "  of  mercury 
substituted. 

One-half  of  the  "  full  dose  "  is  a  "  tonic  dose, "  and  may  be  continued 
steadily  during  several  years  without  injury  to  the  patient;  if  anything, 
apparently  rather  to  his  advantage,  for  he  feels  well  under  it  in  most 


238  VENEREAL   DISEASES. 

cases,  he  eats  well,  his  functions  go  on  perfectly,  and  his  blood  is  richer 
in  red  corpuscles  than  it  was  before.  The  condition  is  an  unnatural  one, 
however.  Nature  is  being  outraged  by  the  constant  use  of  a  foreign  sub- 
stance, which  is  allowable  only  in  order  that  it  may  counteract  another 
foreign  substance — the  poison  of  syphilis — and  the  less  of  the  drug  that 
can  be  used  with  safety  to  the  patient  the  better.  Therefore  it  is 
sometimes  as  well  to  employ  as  a  continuous  dose  a  quantity  somewhat 
smaller  than  the  regular  tonic  dose — a  quantity,  for  instance,  equal  to 
one-third  instead  of  one-half  of  the  "  full  dose  "  in  the  second  six  months 
of  the  disease  when  the  symptoms  are  well  under  control.  This  dose  is 
also  tonic,  and  with  it  one  may  persist  without  interruption,  for  a  long 
period  of  time,  in  the  endeavor  to  eliminate  the  syphilitic  poison  gently, 
and  to  keep  its  explosive  outbreaks  within  reasonable  limits.  The  idea 
of  the  tonic  dose  is  that  it  shall  be  continued  daily,  year  in  and  year  out, 
for,  in  round  numbers,  about  two  years  for  mild  cases  and  longer  for  se- 
vere ones — alterations,  of  course,  being  occasionally  made  meantime,  ac- 
cording to  the  varied  necessity  of  the  different  cases. 

During  the  existence  of  all  ordinary  moderate  symptoms,  isolated 
patches  of  eruption,  disappearing  general  eruptions,  mucous  patches,  etc., 
the  tonic  dose  may  be  maintained  unvaried,  or  slightly  increased,  accord- 
ing to  the  surgeon's  judgment,  while  local  measures  are  brought  to  bear 
upon  the  local  lesions.  If  more  severe  symptoms  come  on  at  any  time, 
the  tonic  dose  may  be  immediately  increased  to  the  full  dose,  already 
ascertained ;  and  after  the  full  dose  shall  have  done  its  work,  it  in  turn 
may  be  again  dropped  to  be  replaced  by  the  tonic  dose.  In  these  emer- 
gencies, instead  of  increasing  up  to  the  full  dose,  the  tonic  dose  may  be 
maintained,  and  inunction  or  fumigation  or  one  of  the  other  internal  mer- 
curial preparations  in  full  dosage  resorted  to  until  the  emergency  shall 
have  passed. 

These  simple  directions  meet  the  wants  of  most  cases  until  some  ter- 
tiary symptom  arrives — if,  indeed,  any  tertiary  symptoms  come  on  at  all, 
for  they  may  be  escaped.  Tertiary  symptoms  call  for  a  variation  in  the 
general  treatment.  The  mercury  may  be  dropped  entirely,  one  of  the 
iodides  being  substituted  if  the  lesion  be  purely  gummatous ;  or  the  mixed 
treatment  may  be  called  for  according  to  the  symptom.  Under  the  heads 
of  the  various  symptoms,  it  will  be  indicated  which  of  the  special  forms 
of  treatment  is  required.  When  the  mixed  treatment  is  indicated,  one  of 
the  best  combinations  is  the  biniodide  of  mercury  in  a  solution  of  the 
iodide  of  potassium. 

After  the  mixed  treatment  or  the  iodides  alone  shall  have  accomplished 
what  was  expected  of  them,  it  is  well  that  the  patient  should  return  again 
to  his  tonic  dose  of  the  granules,  and  continue  them  until  it  is  thought 
best  to  stop  all  treatment. 

In  caso  of  any  intercurrent  malady  not  syphilitic  in  nature  coming  on 


THE   GENERAL,   TREATMENT   OF   SYPHILIS.  239 

during  a  long  mercurial  course,  the  latter  may  be  stopped  at  once  and 
resumed  when  the  intercurrent  malady  has  passed  away.  The  mercury 
should  be  stopped  also  during  any  attack  of  acute  indigestion,  diarrhoea, 
and  the  like. 

A  special  method  of  giving  mercury  internally  is  the  plan  known  as 
Trousseau's  which  is  worthy  of  note.  By  this  plan  minute  doses  of  calo- 
mel, anywhere  from  gr.  ^  to  -fa,  are  given  hourly  or  at  short  intervals, 
with  great  effect  in  some  cases  in  overcoming  the  intense  headache  of 
early  syphilis,  and  for  the  purpose  of  rapidly  bringing  a  patient  under  the 
full  influence  of  mercury.  One-tenth  of  a  grain  hourly  will  show  in  the 
mouth,  in  the  case  of  some  patients,  within  twenty-four  hours,  and  will 
often  purge. 

The  time  at  which  a  tonic  course  of  the  mercurial  specific  may  be 
stopped  is  subject  to  variation.  About  two  and  one-half  years  is  a  full 
course  for  most  people,  while  two  years  answers  well  enough  in  some  cases. 
Six  months  of  entire  immunity  from  symptoms,  at  the  very  least,  or,  better 
still,  a  year's  freedom  from  evidences  of  the  disease,  is  desirable  before 
the  tonic  treatment  is  stopped.  In  some  cases  in  which  smoking  is  per- 
sisted in,  an  occasional  scaly  patch  on  the  side  or  tip  of  the  tongue,  or  in- 
side the  lips  or  cheeks,  need  not  be  regarded  as  a  sj'mptom  serious  enough 
to  make  the  six  months'  test  invalid.  It  is  better  that  no  symptom  what- 
soever suggesting  syphilis  should  have  occurred;  but  it  becomes  a  matter 
of  special  judgment  in  some  cases  whether  the  persistence  of  these  mild 
mouth  lesions,  for  cause  (smoking),  may  not  be  disregarded,  provided  there 
is  and  has  been  nothing  else  about  the  patient  for  a  long  time  to  suggest 
the  persistence  of  the  existence  of  syphilis.  Occasionally,  non-syphilitio 
patients  are  found  in  whom  smoking  will  produce  erosions  and  scaly 
patches  within  the  mouth  absolutely  identical  with  the  lesions  found  in 
syphilis.  Should  such  a  patient  get  the  disease,  it  is  not  fair  to  let  his 
constitutional  peculiarities  be  ascribed  to  a  syphilitic  cause. 

If  relapses  occur  after  the  cessation  of  treatment,  they  must  be  man- 
aged according  to  their  necessities,  generally  best  by  the  mixed  treatment; 
and  then,  finally,  a  tonic  mercurial  course  may  be  instituted  for  a  few 
months,  more  or  less,  according  to  the  judgment  of  the  surgeon,  and  pro- 
portionate to  the  intensity  of  the  relapse  and  its  obstinacy. 

Many  patients  will  not  follow  continuously  the  strict  course  which  has 
been  detailed ;  but  many  others  do  follow  it  conscientiously,  the  more  read- 
ily as  they  are  intelligent  and  have  the  nature  of  the  disease  explained  to 
them,  together  with  the  theory  of  the  treatment. 

Mercurial  Fumigation. — Before  making  use  of  the  standard  dose,  in 
order  to  find  the  full  dose  and  the  tonic  dose  in  a  particular  case ;  or, 
after  the  tonic  dose  has  been  ascertained  and  when  it  is  desirable  suddenly 
to  increase  the  mercurial  influence  in  order  to  counteract  some  tendency 
to  activity  on  the  part  of  the  syphilitic  symptoms — instead  of  putting  the 


240  VENEREAL   DISEASES. 

patient  upon  his  full  dose  of  mercury,  he  may  be  retained  at  the  tonic 
dose,  and  the  mild  but  certain  influence  of  mercurial  fumigation  brought 
to  bear  upon  him.  • 

Mercury  in  vapor  acts  very  promptly  and  very  kindly.  The  obstacles 
to  its  extended  use  are  the  difficulty  of  its  application,  the  time  required 
to  give  a  bath,  the  impossibility  of  using  it  secretly  at  home  (for  syphi- 
litic patients  are  always  shy  of  being  discovered  while  taking  medicine), 
and  the  expense  if  the  baths  are  taken  in  an  outside  establishment. 

The  value  of  the  vapor,  however,  is  so  considerable  in  many  cases 
that  its  use  for  emergencies  should  be  placed  within  the  reach  of  all.  In 
many  ulcerated  and  pustular  lesions,  and  in  cases  in  which  persistent  and 
chronic  relapse  occurs  in  a  patient  with  irritable  stomach  and  general  de- 
bility, the  vapor  bath  renders  invaluable  service.  When  pushed  too  far, 
mercurial  vapor  may  cause  salivation  or  diarrhoea,  but  it  rarely  does  so 
when  watched;  a  sense  of  weakness,  with  general  depression,  attended 
by  more  or  less  trembling  (perhaps  positive  mercurial  tremor),  is  one  of 
the  more  common  indications  that  the  baths  are  being  pushed  too  rapidly. 

In  a  regular  mercurial  bathing  establishment,  the  patient  sits  naked 
in  a  box,  sometimes  with  the  head  in  (if  the  fumes  are  not  disagreeable 
and  do  not  induce  coughing),  sometimes  with  the  head  out.  A  little 
steam  is  let  into  the  chamber,  the  temperature  is  raised  to  90°  F.  or 
thereabouts,  and  when  the  body  is  damp  and  warm  the  mercurial  to  be 
used  is  volatilized,  and,  permeating  the  chamber,  settles  upon  the  moist 
skin,  where  it  becomes  precipitated — changed  probably  into  the  bichlo- 
ride by  contact  with  the  perspiration,  and  as  such  absorbed.  If  the  head 
is  in  the  fumigating  chamber,  a  certain  amount  of  the  vapor  is  directly 
absorbed  by  the  lungs. 

Fifteen  to  twenty  minutes  is  ample  time  for  such  a  bath,  which 
should  be  terminated  sooner  if  the  patient  grows  faint.  The  best  form  of 
mercurial  for  the  bath  I  believe  to  be  the  black  oxide,  in  a  dose  for  vola- 
tilization at  first  of  one  drachm,  afterward  of  two  drachms.  Calomel  is 
often  used,  and  the  sulphuret  of  mercury  in  doses  of  3  i. ;  but  both  of 
these  substances  irritate  the  lungs  of  some  patients  and  may  induce  vio- 
lent coughing.  When  they  are  used,  therefore,  the  head  should  be  kept 
outside  the  fumigating  chamber. 

Twice  a  week  is  generally  often  enough  to  repeat  the  bath.  In  some 
cases,  where  they  are  well  borne,  I  have  repeated  them  daily  for  a  time, 
watching  the  patient  carefully  for  the  effect  of  mercury. 

After  the  bath  the  patient  should  wrap  himself  up  in  a  warm  blanket, 
and  rest  quietly  for  an  hour  or  more,  until  he  has  become  thoroughly  dry 
without  the  use  of  a  towel. 

Domestic  Vapor  Baths. — The  form  of  bath  above  described  is  a  good 
one,  but  it  is  an  expensive  luxury,  and  not  to  be  obtained  at  all  by  pa- 
tients in  the  country.  Under  circumstances  calling  for  a  bath,  in  which 


THE   GENERAL   TREATMENT  OF   SYPHILIS.  241 

the  bathing  establishment  may  not  be  suitable,  an  excellent  substitute,  an- 
swering all  purposes,  may  be  taken  by  the  patient  in  his  own  house  at  a 
merely  nominal  cost.  The  appropriate  essentials  for  such  a  bath  are :  an 
alcohol  lamp  with  one  or  two  good  burners,  and  a  piece  of  tin  bent  into 
the  form  of  a  table  (Fig.  85),  of  such  height  that  the  flame  will  spread 
itself  evenly  upon  the  under  surface  of  the  tin.  The  figure  represents 
the  flames  of  the  lamp  as  being  by  far  too  small.  We  have  found  upon 


FIG.  85. 

such  a  table  that  one  good  flame  of  a  spirit  lamp  will  volatilize  half  a 
drachm  of  calomel  in  four  and  one-half  minutes,  and  the  same  amount 
of  cinnabar  in  six  minutes.  One  flame  is  therefore  ample,  and  it  need  not 
be  a  very  large  flame  if  the  sheet  of  tin  be  reasonably  thin. 

Both  calomel  and  cinnabar  volatilize  quite  easily  by  this  method;  the 
oxides  require  more  heat  and  more  time.  Gray  powder  may  also  be  used. 
Both  calomel  and  cinnabar  (and  especially  the  latter)  may  cause  coughing, 
but  generally  the  bath  can  be  so  managed  that  the  patient  is  not  materi- 
ally discomforted  by  it.  If  cinnabar  be  used,  the  patient  may  keep  his 
head  out,  and  retire  into  another  room  immediately  after  the  bath.  On 
the  whole  calomel  is  to  be  preferred  in  this  form  of  bath,  commencing  by 
volatilizing  a  powder  of  twenty  grains,  and  working  up  to  a  drachm. 

The  simple  method  of  taking  the  bath  is  as  follows:  the  patient 
sits  naked  on  a  cane -bottomed  chair,  holding  close  around  his  neck, 
under  his  chin,  a  couple  of  blankets,  which  may  be  pinned  in  place  so 
as  to  envelop  the  patient  and  the  whole  chair  down  to  the  floor.  Under 
the  blanket  is  placed  the  little  tin  table  beneath  the  chair,  with  its 
spirit  lamp  unlighted,  the  dose  of  calomel  lying  on  top  of  the  tin  table. 
Under  the  chair,  also,  is  placed  a  pan  of  hot  water. 

The  patient  sits  quietly  over  the  hot  water  until  his  skin  has  become 
warmed  up  and  slightly  moist,  then  he  stoops  down,  lights  a  match,  lifts 
the  edge  of  the  blanket,  and  lights  the  spirit  lamp.  He  may  leave  this 
light  burning  until  the  bath  is  finished  if  he  desires,  or  he  may  extin- 
guish it  in  five  or  ten  minutes,  according  to  the  amount  of  calomel  to  be 
volatilized  and  the  degree  of  heat  he  experiences.  He  then  sits  quietly 
for  perhaps  ten  minutes  longer  in  the  fumes,  occasionally  opening  the 
16 


242  .VENEREAL  DISEASES. 

front  of  the  blaukets  to  breathe  a  whiff,  if  the  vapor  does  not  irritate  the 
air  passages.  He  now  wraps  himself  up  in  the  inside  blanket  in  which 
he  has  taken  his  bath,  and  remains  so  wrapped,  lying  down  until  he  has 
cooled  off,  after  which,  without  using  a  towel,  he  goes  to  bed.  In  the 
morning  he  may  take  a  soap  and  warm-water  bath. 

The  effects  of  mercurial  vapor  by  inhalation  may  be  obtained  when  a 
patient  is  unable  to  leave  his  bed  by  volatilizing  calomel  or  cinnabar  near 
his  nose  upon  a  sheet  of  tin,  or  even  upon  a  hot  brick.  Inhalations  of 
this  sort  are  of  incalculable  value  in  some  cases  of  mouth  and  throat 
lesions,  when  the  patient  can  make  the  inhalations  without  coughing, 
which  he  generally  can  do  if  they  are  commenced  mildly  and  often  re- 
peated, minute  quantities  of  mercury  being  volatilized  at  a  time. 

Mercurial  Inunctions. — Inunction  is  the  best  method  of  introducing 
mercury  into  the  bodies  of  infants,  and  many  believe  that  it  is  the  best 
method  in  the  adult.  The  main  objections  to  it  are  that  it  is  dirty,  and 
so  irritates  the  integument  in  some  cases  that  it  cannot  be  used  for  any 
great  length  of  time.  When  it  agrees  it  is  an  excellent  method,  espe- 
cially to  use  in  conjunction  with  the  tonic  internal  treatment,  to  meet  such 
emergencies  as  call  for  an  increase  in  the  amount  of  the  mercurial  em- 
ployed. It  is  as  good  a  method  as  that  by  fumigation  for  sparing  the 
stomach,  and  is  very  useful  in  those  cases  in  which  that  organ  must  be 
restricted  to  its  natural  function,  the  digestion  of  food. 

There  are  many  methods  by  which  mercury  may  be  introduced  through 
the  skin  into  the  blood.  Ordinarily  the  process  is  one  of  friction ;  and 
the  patient  may  do  the  rubbing  himself  with  his  own  bare  hand  or  it 
is  done  by  a  professional  rubber,  who  sometimes  wears  gloves. 

The  amount  of  absorption  which  takes  place  by  the  skin  is  very  varia- 
ble in  different  individuals.  A  prompt  effect  is  produced  in  some 
patients,  a  very  slow  effect  in  others;  consequently,  when  the  course 
must  be  long  or  the  dose  at  all  accurate,  this  method  is  obviously  inap- 
propriate. Moreover,  skins  differ  materially  in  their  irritability  upon  the 
contact  of  mercurial  preparations.  Some  patients  will  wear  a  patch  of 
mercurial  ointment  bound  upon  the  skin  for  weeks  without  showing  any 
local  redness  of  the  skin,  while  in  others  each  inunction  is  followed  by 
local  redness  and  itching,  and  a  persistence  of  the  application  by  an  out- 
crop of  the  so-called  mercurial  eczema  which  distresses  the  patient  consid- 
erably by  its  itching,  and  is,  relatively,  quite  chronic  in  character  and 
slow  to  disappear. 

In  the  friction  method  of  inunction  two  preparations  are  in  use :  mer- 
curial ointment  and  mercurial  vasogen.  Of  the  two  the  mercurial  oint- 
ment is  cheap,  most  easily  procured,  and  generally  preferred.  It  gives 
satisfaction,  and  the  common  ointment  if  freshly  made  is  perfectly  relia- 
ble. There  are  many  special  preparations  which  are  perfectly  good, 
doubtless  better  than  the  common  ointment,  but  the  latter  if  fresh  serves 


THE   GENERAL   TREATMENT   OF   SYPHILIS.  243 

all  purposes.  Among  the  better  preparations  may  be  mentioned  steril- 
ized ointment  put  up  in  gelatin  capsules,  two  and  a  half  and  five  grams 
in  a  capsule,  and  ointments  made  with  lanolin — to  facilitate  absorption. 
The  mercurial  vasogen  is  a  new  proprietary  preparation  made  in  varying 
percentages,  and  alleged  to  be  capable  of  quick  absorption.  A  moderate 
acquaintance  with  it  seems  to  justify  the  claim.  It  is  put  up  in  capsules, 
33  and  50  per  cent  strong,  two  and  three  grams  each,  one  of  which  is 
to  be  rubbed  in  by  the  patient  each  day.  If  it  really  has  unusual  merit 
it  will  remain;  otherwise  it  will  shortly  follow  the  oleates  of  mercury 
and  be  forgotten. 

When  mercurial  ointment  is  to  be  rubbed  in,  from  half  a  drachm  to  a 
drachm  is  a  dose,  to  be  used  once  daily,  preferably  at  night.  The  skin  to 
be  anointed  should  be  thin,  for  the  absorption  of  mercurial  ointment  is 
not  active ;  therefore,  the  flexures  of  the  various  joints  are  usually  chosen, 
although  any  part  of  the  integument  will  answer.  The  lateral  abdominal 
regions  when  not  hairy  are  suitable  regions  and  convenient  for  the  pa- 
tient. 

The  portion  chosen  for  inunction  is  to  be  slowly  and  firmly  rubbed 
with  the  ointment  by  means  of  the  bare  fingers  or  the  whole  hand,  for 
something  like  twenty  minutes  or  half  an  hour.  The  task  is  laborious  if 
properly  done.  The  vasogen  preparation  is  said  to  require  a  shorter 
period  to  obtain  absorption.  After  rubbing  the  ointment  in  as  thoroughly 
as  possible,  the  part  may  be  bound  up  in  dry  flannel  and  left  for  twenty- 
four  hours,  when  it  should  be  carefully  washed  with  soap  and  warm 
water,  and  another  friction  performed  upon  another  portion  of  the  in- 
tegument. 

The  best  inunction  method  when  conducted  by  a  masseur  is  the  fol- 
lowing; it  is  practically  what  is  done  at  the  Hot  Springs:  The  patient 
straddles  a  chair,  leaning  his  arms  and  chin  upon  the  back  of  the  chair. 
He  is  in  a  warm  room,  naked  from  the  waist  upward.  The  rubber  taking 
one-eighth,  one-sixth,  sometimes  one-quarter  of  an  ounce  of  mercurial 
ointment,  rubs  it  broadly  over  the  whole  back  with  a  long  sweeping, 
circular  motion,  and  in  this  way  going  round  and  round,  rubs  the  oint- 
ment thoroughly  into  the  pores  of  the  skin  for  about  twenty  minutes. 
The  patient  now  puts  on  a  thin  gauze  undershirt,  his  mercurial  shirt, 
which  he  wears  through  the  entire  course,  and  goes  about  his  business. 
On  the  following  day,  about  two  hours  before  the  time  for  his  second 
rubbing,  his  attendant  gives  him  a  warm  soap  and  water  bath,  thoroughly 
cleansing  the  back.  Then  the  skin  is  rubbed  down  with  alcohol  and 
clean  underclothing  put  on,  the  skin  being  allowed  to  rest  for  about  two 
hours.  Then  another  inunction  is  given  and  the  original  mercurial  shirt 
again  put  on. 

Teale's  method  of  inunction,  as  it  is  called,  consists  in  binding  upon 
an  arm  or  a  leg  a  piece  of  bandage  (or  flannel  cloth),  upon  which  mercu- 


244  VENEREAL  DISEASES. 

rial  ointment  has  been  thickly  smeared.  The  bandage  is  kept  in  place  at 
discretion,  the  surface  of  the  skin  beneath  it  being  inspected  daily,  and 
the  bandage  removed  and  placed  elsewhere  when  the  skin  begins  to  show 
any  signs  of  redness,  or  the  patient  complains  of  local  itching.  By  this 
means  there  is  a  continuous  action  of  the  mercury  upon  the  skin  day  and 
night  until  the  ointment  dries  up,  when  it  must  be  freshened  with  oil  or 
a  new  plaster  applied. 

This  method  is  mild  and  continuous  in  its  action,  and  with  certain 
skins  works  admirably. 

Hypodermatic  Treatment. — The  only  other  method  of  introducing 
mercury  into  the  body. which  is  worthy  of  consideration  is  that  by  intra- 
muscular injection,  and  when  prompt  effect  is  aimed  at,  one  that  shall  be 
lasting  and  searching,  this  method  is  perhaps  the  best  of  all.  We  keep 
it  constantly  in  mind  for  emergencies.  The  objections  to  it  are,  that 
it  is  often  painful,  may  possibly  suppurate,  but  out  of  several  thousand 
injections  made  by  the  authors  only  two  abscesses  are  of  record;  and,  it 
must  be  borne  in  mind,  an  occasional  fatal  issue  has  been  recorded  after 
intra-muscular  mercurial  injection,  due  to  venous  thrombosis  at  the  seat  of 
puncture  and  pulmonary  embolic  infarction.  The  authors  have  never  en- 
coiintered  a  case,  but  such  cases  have  occurred  at  very  long  intervals  in 
the  best  hands. 

The  preparation  used  for  hypodermatic  medication  is  either  a  soluble 
or  insoluble  mercurial.  The  soluble  preparations  may  be  represented  by 
the  bichloride  of  mercury,  the  insoluble  by  the  mild  chloride  or  calomel. 
The  objections  to  the  bichloride  are  that  it  irritates  sharply  and  like  all 
the  soluble  preparations,  being  eliminated  rapidly,  must  be  employed  at 
too  frequent  intervals.  Calomel  has  been  abandoned  on  account  of  its 
proneness  to  produce  abscess. 

The  preparation  we  have  adopted  and  used  constantly  for  many  years 
is  an  insoluble  one,  the  salicylate  of  mercury.  It  is  prepared  by  mixing 
twenty-four  grains  in  one  ounce  of  sterilized  benzoinol.  The  salicylate 
precipitates  and  must  be  mechanically  mixed  by  violently  shaking  the 
bottle  each  time,  and  an  extra  large  hypodermatic  needle  must  be  em- 
ployed—one and  one-quarter  inches  long  and  with  large  calibre,  that  it  may 
escape  clogging  with  the  insoluble  particles.  We  use  a  syringe  with  an 
asbestos  piston,  which  may  be  boiled  and  kept  surgically  clean.  The  injec- 
tion is  to  be  made  in  the  upper  and  outer  part  of  the  buttock,  the  needle 
being  plunged  in  its  entire  length  and  the  fluid  injected  slowly.  The  in- 
jection must  be  made  aseptically  and  the  little  puncture  closed  with  a  bit 
of  adhesive  plaster.  We  use  thirty  minims  of  this  mixture  usually  at  one 
injection,  one  and  one-half  grains  salicylate  of  mercury,  twice  a  week,  later 
once  a  week.  The  effect  is  often  amazingly  prompt  and  lasting,  and  so 
obvious  that  patients  soon  learn  to  put  up  with  the  discomforts  of  the 
course  rather  than  forego  the  advantages.  In  the  late  patches  of  scaling 


THE   GENERAL   TREATMENT   OF   SYPHILIS.  245 

palmar  and  plantar  syphilide,  so  obstinate  to  almost  all  forms  of  internal 
medication,  these  injections  work  wonders. 

The  direct  local  influence  of  mercury  is  proven  by  subcutaneous  injec- 
tion of  the  drug,  since  it  is  found  that  when  a  patch  of  eruption  is  in- 
jected, it  gets  well,  while  a  similar  patch,  more  or  less  distantly  situated, 
is  not  modified  by  the  general  effect  upon  the  system  of  the  small 
amount  of  mercury  employed. 

Salivation. — In  a  properly  regulated  treatment  salivation  should  never 
occur.  In  ascertaining  what  the  "  full  dose  "  of  mercury  is  in  a  given 
case,  the  gums  may  be  touched,  as  the  expression  is ;  but  this  condition 
cannot  fairly  be  called  salivation,  although  it  is  the  first  stage  of  it.  In 
maintaining  the  full  dose,  the  mouth  is  kept  constantly  in  a  condition  of 
mild  irritation,  and  necessarily  so,  in  some  instances,  when  the  symp- 
toms are  severe.  Under  these  circumstances,  especially  if  it  seems  prob- 
able that  the  full  dose  will  have  to  be  maintained  for  a  considerable 
period,  certain  precautions  should  be  taken  with  the  mouth  in  order  to 
allow  the  mercury  full  chance  without  in  any  way  encouraging  its  dis- 
agreeable effect  upon  the  mouth. 

The  teeth,  it  is  presumed,  have  been  properly  attended  to,  and  the 
tartar  removed  by  a  dentist.  All  the  precautions  detailed  in  speaking  of 
the  hygiene  of  the  mouth  should  also  be  put  in  force.  Besides  these, 
three  other  precautions  may  be  resorted  to ;  they  are :  the  bath,  a  diu- 
retic, and  the  internal  use  of  the  chlorate  of  potassium. 

The  bath  should  be  used  quite  hot  at  night,  and  the  patient  advised  to 
remain  for  a  number  of  minutes  in  the  warm  water.  Then  he  should  dry 
his  skin  under  very  smart  friction  with  a  soft  towel.  In  this  way  the 
circulation  of  the  skin  is  rendered  active,  and  the  dead  epidermis  rolled 
off  in  quantities  by  the  friction.  The  function  of  the  skin  as  an  excretory 
organ  is  intensified,  and  more  mercury  than  usual  escapes  in  this  direc- 
tion, taking  off  some  of  the  work  from  the  mouth. 

A  diuretic  acts  in  the  same  way,  increasing  the  excretory  activity  of 
the  kidney,  and  allowing  more  mercury  to  escape  from  the  body  by  this 
channel. 

Finally,  the  well-known  soothing  influence  of  the  chlorate  upon  the 
irritated  mouth  and  fauces  should  be  called  into  play.  A  little  less  than 
a  drachm  of  the  chlorate  of  potassium  in  twenty-four  hours  is  generally 
enough. 

B  Potass,  chlorat., 3  i- 

Aquse  gaultheriae, §  ii  j. 

M.     S.  Teaspoonful  hourly  in  a  tablespoonful  of  flaxseed  tea. 

As  salivation  approaches,  the  stale  odor  of  the  breath  becomes  posi- 
tively offensive,  quite  peculiar  and  characteristic — the  mercurial  fetor,  as 
it  is  called.  The  tongue  becomes  heavily  coated,  and  the  peculiar,  bitter, 
coppery  taste  of  which  the  patient  has  been  complaining  grows  sensibly 


246  VENEREAL  DISEASES. 

more  intense  and  more  disagreeable,  especially  upon  awakening  in  the 
morning.  The  gums  grow  puffy,  soft,  and  fungating  along  the  line  of 
the  necks  of  the  teeth,  more  livid  in  color,  bleeding  easily  upon  the  light- 
est touch,  as  during  brushing  the  teeth,  even  with  the  softest  tooth-brush. 
Finally,  the  flow  of  saliva  grows  more  and  more  profuse,  partly  watery 
and  partly  tenacious.  It  flows  over  upon  the  patient's  chin,  and  soils  his 
clothes.  At  night  it  runs  out  from  the  angles  of  his  mouth,  and  wets 
his  pillow.  With  these  signs  the  stomach  is  often  badly  upset,  diarrhoea 
comes  on,  the  complexion  becomes  pallid,  livid,  the  appetite  fails,  and 
headache  is  often  present,  with  great  depression  of  spirits. 

At  last  the  tongue  may  swell  so  as  to  be  too  large  for  the  mouth,  and 
with  it  the  lips  and  cheeks  become  tumid.  Ulcers  appear  all  over  the 
inside  of  the  mouth  and  along  the  gums.  The  purple  gums  bleed  freely, 
the  loosened  teeth  project  and  drop  from  their  sockets,  while  more  or 
less  extensive  portions  of  bone,  or  of  the  soft  parts,  necrose  and  slough 
away. 

Such  an  intense  condition  of  salivation  as  that  last  depicted  is  very 
rarely  encountered  at  the  present  day,  but  it  need  not  be  waited  for ;  all 
conditions  of  active  salivation  demand  prompt  measures  for  their  relief. 

All  the  means  of  relief  already  detailed  under  the  head  of  hygiene  of 
the  mouth,  and  directed  for  the  restraint  of  salivation  when  the  gums  are 
mildly  touched,  should  be  kept  in  force,  as  far  as  may  be,  and  atropine 
used  in  solution  under  the  skin. 

No  one  remedy  perhaps  acts  as  kindly  as  this.  Of  the  following  solu- 
tion— 

1^  Atropinse  sulph.  ,        .         .        .         .         .         .         .         .  gr.  i. 

Aquae,  .        . §  i. 

M. 

Five  minims  may  be  thrown  under  the  skin,  the  effect  upon  the  pupil 
being  watched,  and  the  dose  repeated  every  four  to  six  hours  until  the 
pupils  are  widely  dilated. 

Chlorate  of  potassium  in  solution,  in  cold  tea,  about  one  or  two  drachms 
to  the  pint,  with  a  scruple  of  carbolic  acid,  according  to  the  sensitiveness 
of  the  swollen  mouth,  should  be  constantly  used  as  a  mouth  wash,  and 
gradually,  as  they  can  be  borne,  stronger  and  more  astringent  washes. 
To  all  of  these  a  little  carbolic  acid  should  be  added,  for  the  mouth  and 
its  secretions  are  most  foul  and  need  sweetening  greatly.  A  reasonably 
good  mouth  wash  is  the  following,  diluted  at  first  with  warm  water, 
should  it  prove  too  astringent: 

Ifc  Acid,  carbolic., gr.  x. 

Acid,  tannic., 3  i. 

Tr.  myrrhse, 3  i j. 

Potass,  chloratis, 3  ij. 

Mellis, ^ij. 

Aquae  menth.  pip., q.8.  -ad   §  viij. 


THE   GENERAL,  TREATMENT   OF   SYPHILIS.  247 

Peroxide  of  hydrogen  diluted,  or  a  mild  solution  of  borax  or  of  per- 
manganate of  potassium,  may  be  used  as  a  substitute  for  the  carbolic-acid 
preparations  should  the  latter  be  offensive,  as  they  are  to  some  patients. 

Diarrhoea  in  these  cases  may  be  disregarded,  unless  it  is  exceptionally 
severe.  Nourishment  must  be  maintained  mainly  by  milk,  eggs,  soups, 
and  soft  food.  The  patient  should  drink  water  freely. 

Local  Treatment. — The  local  treatment  of  syphilis,  although  subor- 
dinate to  the  general  treatment,  is  nevertheless  of  great  importance  in 
many  cases.  This  is  especially  true  in  regard  to  mouth  lesions,  and  those 
occurring  about  the  anus  and  genitals  in  either  sex.  It  may  also  be  re- 
quired for  aesthetic  purposes  to  remove  eruption  that  shows  upon  the  face, 
scalp,  or  hands,  and  to  assist  in  cicatrizing  ulcerated  areas. 

In  connection  with  a  description  of  the  varied  local  lesions,  some  of 
the  local  measures  of  treatment  most  appropriate  to  them  will  be  alluded 
to;  but,  for  the  sake  of  avoiding  endless  repetition,  it  is  well  to  group 
under  one  head  all  general  remarks  about  the  local  treatment  of  the 
varied  lesions  of  syphilis,  only  repeating  afterward  when  the  treatment 
is  to  be  emphasized. 

In  general,  then,  it  may  be  said  that  all  the  local  expressions  of 
syphilis  should  be  treated  with  respect,  not  irritated  by  much  handling, 
by  dirt,  by  allowing  the  secretions  to  be  retained  and  to  undergo  decom- 
position. Ulcers  should  be  kept  clean,  discharges  of  all  sorts  should  be 
frequently  washed  away,  tobacco  prohibited  when  mouth  lesions  exist. 

Lesions  Upon  the  Skin. — The  local  treatment  of  chancre  is  detailed 
along  with  the  description  of  the  lesion.  The  early  general  eruptions  re- 
quire no  local  treatment  other  than  cleanliness,  unless  it  be  for  such  por- 
tions of  the  eruption  as  appear  upon  the  face  and  hands.  These  portions, 
therefore,  may  be  treated  topically  while  the  rest  of  the  eruption  is  al- 
lowed to  subside  under  general  medication. 

The  best  topical  applications  for  all  the  forms  of  secondary  and  inter- 
mediary syphilis  appearing  upon  the  skin  are  the  different  preparations 
of  mercury.  Most  of  the  tertiary  lesions  do  well  also  under  a  local  use 
of  the  mercurials ;  but  some  ulcerative  forms  seem  to  thrive  better  when 
dressed  with  iodoform,  nosophen,  or  aristol. 

The  mercurials,  to  be  effective  of  good  by  local  application,  should  be 
graded  in  strength  so  as  to  stimulate  without  irritating  the  surface.  Con- 
sequently there  must  be  a  range  in  the  strength  of  all  applications  em- 
ployed, and  it  is  well  in  a  given  case  to  begin  with  a  mild  ointment, 
increasing  its  strength  according  to  its  effect.  Dry  lesions  call  for  more 
strength  in  the  local  application  than  excoriated  surfaces  require. 

The  preparations  from  which  have  been  derived  the  most  service  are 
the  following :  l 

1  Most  of  these  have  appeared  in  the  monograph  on  "  Tonic  Treatment  of  Syph- 
ilis," E.  L.  Keyes,  published  in  1896,  p.  71. 


248  VENEREAL  DISEASES. 

$  Hydrarg.  oleat.,     .        ....        .        .        •  5-10  per  cent. 

Or— 

B  Hydrarg.  chlorid.  corrosiv.,  .         ••'.'•         •         •  &•  ^~v- 

Glycerinae, 3ss. 

Spts.  rect., 

Aquae  ros., aa  §ss. 

M. 
Or— 

E  Hydrarg.  chlorid.  mitis, 3  i--ij- 

Ungt.  aquae  ros. ' i  i. 

M. 
Or- 

]$  Hydrarg.  ammoniat., 3  i.-ij. 

Ungt.  aquae  ros., §  i. 

M. 
Or- 

B  Hydrarg.  oxid.  rub., 3  ss.-i j. 

Ungt.  aquae  ros., 1  i. 

M. 
Or— 

E  Ung.  hydrarg.  nitratis,  .....  q.s. 

To  be  used  in  the  beginning  much  diluted. 
Or— 

1$  Hydrarg.  iodid.  virid., gr.  xv.-l. 

Ungt.  aquae  ros. , 3  i- 

M. 
Or— 

E  Hydrarg.  oxid.  flav., gr.  xx.-  3  iss. 

Ungt.  aquae  ros., .    3  i. 

M. 

Among  these  preparations,  perhaps  the  best  are  the  lotion  of  the 
bichloride,  the  white  precipitate,  and  the  citrine  ointments.  One  or  the 
other  of  them  will  be  found  to  serve  a  good  purpose  in  the  case  of  the 
different  cutaneous  lesions,  dry  or  moist. 

Ulcerated  lesions  upon  the  integument,  due  to  late  syphilis,  generally 
improve  under  various  local  mercurial  applications.  The  black  and  yel- 
low washes  of  the  pharmacopoeia  serve  a  good  purpose,  as  does  also  a  mild 
solution  of  the  bichloride  of  mercury,  or  dusting  the  surface  with  calomel. 

Gummatous  and  serpiginous  ulcers  sometimes  improve  under  these 
applications,  but  sometimes  they  do  not.  In  such  case  it  is  well  to  try 
iodoform  in  fine  powder,  or  rubbed  up  into  a  paste  with  glycerin,  or  dis- 
solved in  chloroform,  remembering  that  the  chloroform  solution  is  some- 
times a  painful  application. 

1  Any  other  bland  excipient  may  be  used.  Vaseline  is  perhaps  the  best  if  the 
ointment  isto  be  kept  for  any  length  of  time,  since  it  does  not  become  rancid.  Oint- 
ments made  with  vaseline,  however,  are  somewhat  less  active  than  if  another  fat  is 
used  as  an  excipient,  and  absorption  is  more  prompt  if  lanolin  be  used. 


THE   GENERAL   TREATMENT   OF   SYPHILIS.  249 

A  watery  solution  of  chloral  hydrate  does  very  well  in  some  old,  slug- 
gish cases,  from  gr.  v.  to  xv.  to  the  ounce  of  water. 

Ulcers  on  the  leg,  if  old  and  chronic,  often  improve  at  once  upon 
the  use  of  Martin's  rubber  bandage,  or  any  other  species  of  strapping, 
while  some  phagedenic  forms  of  ulcer  ought  to  be  allowed  the  chance 
of  benefit  promised  by  the  continuous  submersion  system  described  on  p. 
191.  Chronic  syphilitic  ulcers  with  hard  edges  do  well  if  their  edges  are 
scarified  and  poulticed  at  first.  Ulcers  communicating  with  necrosed  or 
carious. bone,  or  with  sinuses  leading  into  joints,  cannot  be  expected  to 
get  well  until  the  deeper-seated  lesions  have  been  overcome. 

Lesions  upon  the  Mucous  Membranes.  —  Great  cleanliness  is  the 
first  requisite  in  treating  syphilitic  lesions  of  mucous  membranes.  The 
mouth  must  be  subjected  to  all  the  rules  mentioned  in  connection  with 
the  hygiene  of  the  mouth,  and  astringent  mouth  washes,  as  well  as  some 
of  the  other  measures  suggested  in  cases  of  salivation  (p.  191),  may  do 
good.  Tobacco  must  be  stopped  in  the  case  of  mouth  lesions ;  the  vagina 
and  vulva  should  be  syringed  and  washed  frequently  in  the  event  of  le- 
sions in  this  quarter;  constipation  must  be  avoided,  and  cleanliness  en- 
joined whenever  the  rectum  is  threatened  with  trouble  or  becomes  the 
actual  seat  of  lesions. 

'Mouth  lesions  are  the  most  common  and  most  likely  to  be  protracted. 
Steaming  the  throat  and  mouth,  gargles  of  peroxide  of  hydrogen,  of  infu- 
sion of  flaxseed,  of  warm  tea,  with  or  without  a  little  borax,  gr.  x.-xx. 
to  3  i.,  or  chlorate  of  potassium,  gr.  v.-xv.  to  §  i.,  have  an  excellent  sooth- 
ing effect  in  these  cases.  A  certain  amount  of  chlorate  of  potassium  should 
be  swallowed,  that,  by  returning  into  the  mouth  in  solution  in  the  saliva, 
it  may  keep  up  a  constant,  mild,  soothing  action  upon  the  various  lesions. 

One  excellent  expedient,  in  cases  in  which  mouth  lesions  are  constantly 
recurring,  is  to  give  whatever  mercury  may  be  required  for  general  treat- 
ment in  the  form  of  tablet  triturates  of  bichloride  of  mercury,  which  may 
be  allowed  to  dissolve  slowly  in  the  mouth,  the  saliva  being  swallowed. 
In  this  way  the  local  effect  of  a  solution  of  corrosive  sublimate  upon  the 
mouth  lesions  is  obtained  at  the  same  time  with  the  carrying  out  of  gen- 
eral treatment. 

The  best  local  applications  to  make  upon  syphilitic  mouth  lesions  are 
solutions  of  corrosive  chloride  of  mercury. 

R  Hydrarg.  chlorid.  corrosiv., gr.  ij.-v. 

Spts.  rect., 3  i. 

M. 

To  be  painted  over  the  affected  surfaces  with  a  soft  brush  daily. 

Or,  the  acid  nitrate  of  mercury,  pure,  in  small  quantity,  touched  upon 
the  lesion  once  a  week; 

Or,  applications  of  the  nitrate  of  silver,  or  of  the  nitrate  of  zinc,  solid 
or  in  solutions  of  varying  strengths ; 


250  VENEREAL   DISEASES. 

Or,  the  daily  use  of  a  solid  lump  of  pure  sulphate  of  copper,  which  is 
to  be  lightly  rubbed  over  the  lesion. 

Mercurial  fumigations  (p.  240)  are  of  the  utmost  value  in  many  forms 
of  mouth  lesion. 

In  cases  of  pure  gummata  of  the  mouth  and  throat,  it  is  best  not  to 
waste  time  with  mercurial  local  applications,  since  attention  in  this  way 
may  be  diverted  from  the  main  hope  in  such  cases — the  unsparing  use  of 
the  iodide  of  potassium  internally. 

Upon  the  vulva,  vagina,  beneath  the  prepuce,  and  elsewhere,  the 
same  general  line  of  treatment  is  to  be  followed  as  for  similar  lesions 
within  the  mouth — cleanliness  being  perhaps  of  more  value  than  any  oth- 
er one  local  method  of  treatment.  Pedunculated  condylpmata,  or  other 
vegetations,  may  be  snipped  off  and  the  base  from  which  they  grow 
cauterized,  or  they  may  be  treated  with  the  salicylic  acid  and  acetic  acid 
compound  (page  59). 

Mucous  patches  about  the  angles  of  the  mouth,  upon  the  lips  and 
face,  generally  do  well  under  the  local  application  of  the  solution  of  the 
bichloride  of  mercury.  If  this  does  not  hurry  them  away,  one  or  two 
light  applications  of  the  acid  nitrate  of  mercury  usually  leave  nothing 
to  be  desired  in  the  way  of  efficiency. 

When  mucous  patches  occur  about  the  anus,  under  the  foreskin,  on 
the  sides  of  the  scrotum,  or  about  the  vulva,  between  the  toes,  under  the 
breast  in  the  female,  in  any  region  where  overlying  portions  of  the  skin 
keep  the  surfaces  of  the  lesions  sodden,  retain  their  secretion,  and  encour- 
age putridity  of  the  moisture  as  it  collects — in  any  of  these  contingencies, 
soap  and  warm  water,  followed  by  a  mild  dilution  of  Labarraque's  solu- 
tion, of  permananate  of  potassium,  or  of  carbolic  acid,  are  great  aids  to 
treatment. 

The  lesions  must  also  be  kept  dry,  if  possible,  either  by  interposing 
layers  of  thin  old  linen,  absorbent  cotton,  or  prepared  lint,  between  the 
surfaces  which  lie  in  contact,  or  by  a  plentiful  use  of  some  absorbent 
powder,  such  as  talcum,  bismuth,  oxide  of  zinc.  A  very  effective  way  of 
treating  these  lesions  is  to  dust  them  plentifully  and  often  with  pure  cal- 
omel, or  with  calomel  in  varying  proportions  combined  with  one  of  the 
inert  dry  powders  mentioned  above. 

All  that  is  required  besides  this,  even  in  bad  cases,  is  to  touch  the 
separate  moist  lesions  with  solutions  of  nitrate  of  silver  of  varying 
strength,  gr.  x.-  3  i.  to  the  ounce  of  water;  or  lightly  with  the  solid  stick 
of  lunar  caustic ;  or,  perhaps  better  still,  to  use  the  solution  of  the  bichlo- 
ride of  mercury  already  recommended  for  skin  lesions. 


CHAPTER  IX. 

THE  GENERAL  TREATMENT  OF  SYPHILIS  (Continued). 

The  Iodide  Preparations. — For  the  purely  gummatous  lesions  no  drugs 
equal  the  iodides  given  unsparingly.  Unfortunately,  the  popular  dislike 
to  mercury  is  shared  by  many  physicians ;  and  these  gentlemen,  in  look- 
ing around  for  a  specific  for  syphilis  which  is  not  mercury,  often  fall  upon 
the  iodides  and  administer  them  in  different  vegetable  infusions  and  tinc- 
tures from  the  very  beginning  of  syphilis,  praising  themselves  and  calling 
for  the  applause  of  their  patients  in  that  they  give  no  mercury.  It  is  better, 
doubtless,  to  treat  early  syphilis  with  iodide  of  potassium  than  not  to 
treat  it  at  all ;  but  exactly  how  much  better,  it  is  hard  to  estimate.  The 
iodides  have  little  power  in  postponing  eruptions  that  are  to  come,  although 
they  do  clear  up  existing  lesions.  They  certainly  have  little  or  no  power 
in  preventing  relapse  either  early  or  late  in  the  disease.  The  iodides 
have  their  place,  and  a  very  important  place  it  is ;  but  it  is  unfortunate 
that  they  are  accredited  with  much  curative  power  over  syphilis,  since  this 
notion  naturally  leads  to  their  abuse,  and  tends  to  bring  them  into 
disrepute. 

Whenever  the  lesion  is  gummatous,  in  most  of  the  intermediary  and 
late  syphilides,  and  whenever  the  proliferative  changes  of  connective  tis- 
sue so  common  in  advanced  syphilis  in  the  internal  organs  are  going  on, 
the  iodide  of  potassium  is  a  power,  and  an  enormous  power,  which  may 
be  used  to  the  great  advantage  of  the  patient,  either  alone  in  very  large 
doses  in  appropriately  selected  cases,  or  in  combination  with  mercury,  in 
more  moderate  doses — constituting  what  is  known  as  the  mixed  treat- 
ment. 

When,  however,  the  symptoms  for  which  the  iodide  is  used  have  been 
fairly  and  entirely  overcome,  then  the  mercurials  resume  sway,  and  it  is 
better  shortly  to  drop  the  iodides,  holding  them  in  reserve  for  other 
emergencies. 

The  preparations  of  iodine  most  valuable  in  syphilis  are  the  iodides 
of  potassium  and  of  sodium.  The  iodides  of  calcium,  starch,  and  ammo- 
nium are  also  used,  and  iodine  as  tincture,  simple  and  compound,  and 
in  the  shape  of  iodoform  internally.  The  last  may  be  spoken  of  first,  in 
order  to  dispose  of  them. 

Little  or  no  iodine  effect  can  be  expected  from  iodoform  internally, 


252  VENEREAL   DISEASES. 

given  in  doses  of  a  fraction  of  a  grain  up  to  five  grains  at  a  time.  Hill 
has  spoken  well  of  it  in  gumma  of  the  tongue,  but  we  have  not  found  it 
serviceable.  The  senior  author  has  given  thirty  grains  at  a  dose,  with 
no  obvious  effect. 

The  tincture  of  iodine  and  the  compound  tincture  in  starch  water 
(forming  the  fresh  iodide  of  starch)  may  sometimes  be  used  with  advan- 
tage. It  is  very  dark  to  look  at,  and  not  pleasant  to  the  taste,  being  flat, 
rather  nauseating  than  otherwise;  but  it  is,  on  the  whole,  bland  and 
rather  easily  digested,  and  in  cases  in  which  the  iodide  of  potassium  or  so- 
dium was  badly  borne  by  the  stomach  the  mixture  has  value.  The  tinc- 
tures may  be  used  in  doses  of  ten  drops  in  a  tablespoonf  ul  or  more  of 
starch  water,  and  increased  up  to  eighty  drops  in  a  claret-glass  of  the 
diluting  fluid.  The  iodide  of  starch  in  the  form  of  a  dry  powder  may 
be  used  in  from  gr.  x.  to  xxx.  doses.  It  is  very  bulky  and  difficult  to 
take.  The  iodide  of  starch  cannot  be  relied  upon  in  an  emergency.  It 
is  valuable  mainly  in  some  chronic  conditions  and  as  an  alternate  to  other 
iodides. 

The  iodide  of  ammonium  is  generally  used  in  combination  with  other 
iodides,  under  the  idea  advanced  by  Paget  and  sustained  by  Hutchinson, 
that  the  carbonate  of  ammonia  given  in  combination  with  the  iodide  of 
potassium  intensified  the  action  of  the  latter. 

The  iodides  of  potassium  and  of  sodium  and  of  strontium  hold  the 
first  rank  among  the  preparations  of  iodine  as  specifics  against  syphilitic 
gummata.  Of  these  the  first  named  is  the  most  powerful,  but  it  has  the 
disadvantage  of  being  decidedly  more  irritating  to  the  stomach  than  the 
iodides  of  sodium  or  of  strontium.  The  last  named  is  decidedly  the 
easiest  to  digest,  and  the  best  preparation  in  the  market  seems  to  be  the 
French  imported  bearing  the  name  of  Chapoteaut.  It  makes  a  solution  in 
distilled  water  a  grain  to  the  minim.  This  drug  is  rather  expensive  and 
liable  to  be  adulterated. 

The  bitter,  coppery  taste  which  the  iodides  produce  in  the  mouth  of 
the  patient,  and  most  obvious  in  the  morning  upon  first  awaking,  is  a 
drawback  in  some  cases  to  the  free  use  of  the  remedy.  Occasionally  the 
mouth  is  made  sore  by  long-continued  use  of  the  iodides,  the  gums  get 
tender  and  spongy,  they  swell  as  in  true  salivation,  and  a  certain  amount 
of  soreness  in  the  teeth  is  complained  of,  together  with  an  increased  flow 
of  saliva — the  whole,  indeed,  forming  a  sort  of  spurious  salivation. 
These  two  lesser  evils  may  be  measurably  abated :  the  first,  by  the  use  of 
peppermint  in  some  form,  both  at  the  time  of  taking  the  dose  and  upon 
awaking  in  the  morning,  and  by  chewing  pieces  of  root  licorice ;  the  sec- 
ond, by  the  use  of  astringent  mouth  washes,  diuretics,  and  such  remedies 
as  are  generally  useful  in  true  salivation. 

Besides  these  lesser  evils  sometimes  attending  the  use  of  the  iodides, 
there  are  five  other  serious  discomforts  which  are  attached  to  their  em- 


THE    GENERAL,   TREATMENT   OF   SYPHILIS.  253 

ployment :  acute  catarrh,  headache,  iodism,  cutaneous  eruptions,  and  irri- 
tation of  the  stomach. 

Acute  catarrh,  to  the  extent  occasionally  of  rendering  the  patient  very 
miserable,  sometimes  comes  on  at  the  very  beginning  of  the  use  of  the 
iodides.  The  patient  sneezes  and  coughs,  the  eyes  grow  red  and  watery, 
the  nose  runs,  and  with  this  sometimes  comes  an  intense  pain  across  the 
brow,  and  perhaps  severe  headache.  This  symptom,  like  most  of  the 
others  due  to  the  iodides,  varies  in  intensity  with  the  strength  of  the 
dose.  Unlike  some  of  the  other  symptoms,  it  often  wears  off  as  the  iodide 
is  continued  in  use,  or  at  least  the  patient  gets  accustomed  to  it  and  com- 
plains less. 

The  treatment  of  this  catarrh  is  to  keep  the  skin  active  by  the  use  of 
warm  baths,  to  give  the  patient  plenty  of  bland  fluids  to  drink,  and  to 
encourage  the  action  of  the  kidneys,  the  proper  channels  of  exit  for  the 
iodides.  Belladonna  internally,  in  small  quantities,  has  a  certain  amount 
of  influence  in  controlling  the  amount  of  secretion  from  the  nose  and 
throat. 

The  headache  produced  in  some  people  by  the  use  of  the  iodides  is 
quite  intense.  It  usually  occupies  the  brow,  or  the  side  or  the  whole  top 
of  the  head.  The  headache  comes  on  sometimes  after  a  single  dose  of 
the  offending  drug,  and  sometimes  is  so  intense  that  it  constitutes  a  posi- 
tive bar  to  the  continued  use  of  the  remedy.  Fortunately,  cases  of  this 
sort  are  quite  rare. 

The  only  treatment  is  to  give  a  mild  diuretic  in  combination  with  the 
iodide,  and  to  add  some  of  the  bromide  of  potassium  to  the  mixture,  or 
even  a  little  opium.  Fortunately,  this  idiosyncrasy  of  having  headache 
when  taking  the  iodides  is  not  always  an  affair  of  a  lifetime ;  the  patient 
generally  outgrows  it  in  time. 

Iodism,  properly  speaking,  includes  the  headache  and  catarrh  already 
alluded  to ;  but  the  main  feature  in  iodism  proper  is  a  peculiar  and  intense 
nervous  depression,  with  irritability.  This  occurs  in  certain  individuals 
when  they  take  the  iodides.  With  this  depression  there  may  be  more  or 
less  ringing  in  the  ears,  pain  in  the  bones,  etc. 

Iodism  is  difficult  to  overcome  by  treatment ;  usually  all  efforts  fail. 
The  general  means  mentioned  above  for  the  headache  of  iodine  may  also 
be  tried  here. 

The  cutaneous  eruptions  produced  by  the  iodides'  are  numerous. 
Erythema,  with  considerable  scaling  of  the  skin,  and  acne,  with  boils 
about  the  face,  nose,  back,  shoulders,  and  buttocks,  are  not  uncommon 
results  of  their  use.  Purpura  hsernorrhagica  is  produced  by  the  iodides, 
especially  in  debilitated,  anaemic  persons  who  have  taken  the  drug  for  a 
long  time.  A  peculiar  form  of  pemphigoid  eruption  occurring  in  groups, 
and  sometimes  called  hydroa  (Hutchinson),  is  another  of  the  evil  results 
of  the  iodides  upon  the  skin  of  some  patients. 


254  VENEREAL.  DISEASES. 

The  irritation  produced  in  the  stomach,  and  sometimes  in  the  intestine 
by  the  iodides,  especially  when  used  in  large  doses,  is  another  seriously 
bad  quality  which  they  possess.  In  this  way  nausea  and  lack  of  appe- 
tite may  be  induced,  going  on  sometimes  to  diarrhoea,  and  leading  to 
anaemia  and  loss  of  strength — misfortunes  which  do  so  much  to  coun 
teract  the  good  effects  produced  by  the  drugs. 

This  irritation  of  the  stomach  and  skin  attaches  often  to  an  imperfect 
elimination  of  the  drug  by  the  kidneys.  When  a  patient  is  under  full 
doses  of  the  iodides,  his  urine  is  full  of  them,  as  may  be  demonstrated 
by  pouring  a  little  nitric  acid  into  a  test  tube  containing  some  of  the 
urine.  The  stronger  acid  attacks  the  salt  and  liberates  the  iodine,  which 
colors  the  urine,  lying  above  the  layer  of  acid.  If  the  kidneys  do  not  do 
their  duty  properly,  some  of  the  cutaneous  expansions  of  the  body  must 
suffer:  it  may  be  the  membrane  of  the  nose;  it  may  be  the  skin  of  the 
face  or  back,  or  the  glands  this  skin  contains ;  or  it  may  be  the  stomach. 
The  stomach  is  also  particularly  exposed  to  irritation  by  direct  contact 
with  the  medicine.  This  direct  contact  the  stomach  always  resents, 
especially  if  the  drug  be  presented  to  it  in  a  concentrated  form,  when  it 
is  empty. 

The  natural  deduction  from  all  this  is  that  the  kidneys  must  be  kept 
always  active,  when  the  iodides  are  being  administered,  by  the  use  of 
plenty  of  water  and  bland  fluids  on  the  part  of  the  patient,  as  well  as  by 
diluting  the  drug  largely  when  it  is  taken,  and  giving  it  always  upon  a 
full  stomach.  If  these  means  do  not  suffice,  the  dose  of  the  iodide  may 
be  combined  with  a  more  active  diuretic — such  as  the  acetate  of  potassium, 
or  the  infusion  of  digitalis,  or  both. 

Sometimes,  in  spite  of  all  precautions,  the  iodides  cannot  be  taken  by 
the  stomach.  Under  such  circumstances  they  may  be  administered  by 
the  rectum,  giving  ten-  and  fifteen-grain  doses  of  the  iodide  of  potassium 
or  sodium  dissolved  in  an  ounce  of  warm  beef -tea. 

Above,  all  it  must  be  borne  in  mind  that  the  iodides  should  never  be 
given  solid  (in  pill  form)  when  their  use  in  large  quantities  is  required. 
Small  doses  in  pill  form  do  very  well  in  some  cases,  as  high  as  gr.  v.  of 
the  iodide  in  each  pill ;  but  such  pills  should  be  given  only  upon  a  full 
stomach,  or,  perhaps  better,  taken  during  the  middle  of  a  meal. 

When  it  becomes  absolutely  necessary  to  push  the  iodides,  it  should 
be  done  in  spite  of  all  obstacles  to  the  contrary.  It  may  be  necessary  to 
restrict  the  diet  and  to  give  bismuth  and  a  little  opium  even,  but  when 
the  iodides  are  needed  they  must  be  pushed  at  any  cost. 

The  dose  of  the  iodides  is  about  five  grains  to  commence  with  in  an 
ordinary,  untried  case,  and  when  there  is  no  emergency  to  deal  with. 
This  five-grain  dose  will  generally  indicate  in  what  way,  if  at  all,  the 
patient  is  to  be  uncomfortably  affected  by  the  iodides.  An  occasional 
pimple  of  acne  on  the  forehead  or  temple  is  generally  all  that  will  be 


THE   GENERAL,  TREATMENT  OF  SYPHILIS.  255 

seen,  with  perhaps  a  little  excess  of  secretion  from  the  mucous  membrane 
of  the  nose  during  the  first  few  days  ..of  the  course.  For  an  ordinary 
case,  when  there  is  no  haste  and  the  stomach  is  to  be  respected,  the  dose 
of  the  iodide  may  be  pushed  by  an  increase  of  two  and  a  half  grains  in 
the  dose  each  week.  By  such  a  gradual  increase,  with  a  little  care,  the 
stomach  need  not  be  injured,  the  skin  is  not  likely  to  give  much  trouble, 
and  the  weekly  increase  in  the  dose  may  be  suspended  when  the  symptoms 
have  fairly  yielded. 

No  such  caution,  however,  can  be  indulged  in  when  an  emergency  is 
at  hand.  When  the  soft  palate  is  threatened  with  rapid  destruction  by  a 
perforating  gummy  ulcer,  when  the  bones  of  the  nose  are  crackling  under 
the  touch,  when  the  functions  of  the  brain  are  involved  or  life  is  threatened, 
then  there  is  no  time  for  hesitation  or  delay,  and  it  is  not  necessary  to 
ask  whether  the  iodide  will  agree  or  not.  If  it  does  not  agree,  it  must  be 
made  to  agree — a  process  which  may  tax  the  resources,  the  ingenuity, 
and  the  patience  of  the  surgeon  to  the  utmost.  Under  such  circum- 
stances, a  dose  of  ten  grains  every  four  hours  is  a  moderate  beginning, 
and  in  one  or  two  days,  according  to  the  surgeon's  judgment  and  the 
patient's  necessities,  the  dose  may  be  increased  by  five  or  ten  grains,  and 
so  on  indefinitely  until  the  symptoms  yield  or  the  stomach  refuses  to 
receive  the  drug. 

In  such  a  case  the  stomach  must  be  managed  with  all  care  in  the  man- 
ner suggested  above,  and  opium,  if  need  be  bromides  or  diuretics,  with 
bland  food,  judiciously  joined  to  the  iodides  in  such  a  way  that  the  stom- 
ach shall  have  no  excuse  for  rebellion.  Limit  to  the  dose  there  is  none: 
the  signal  to  stop  increasing  the  dose  in  a  desperate  case  is  unconditional 
surrender  on  the  part  of  the  symptoms.  If  the  diagnosis  has  been  accu- 
rate and  the  stomach  can  be  managed,  this  result  will  follow  as  surely  as 
the  night  follows  day.  The  physician  need  have  no  fear,  there  need  be 
no  hesitation.  If  the  stomach  holds  out,  and  the  drug  is  boldly  and  in- 
telligently pushed,  victory  is  the  one  and  only  result.  All  minor  symp- 
toms of  iodism  may  be  disregarded,  the  eruptive  troubles,  the  catarrh, 
even  the  headache  and  depression  of  spirits,  although  these  last  make 
some  patients  desperate,  so  that  they  seem  willing  to  suffer  anything 
from  the  disease  rather  than  to  be  compelled  to  continue  their  medicine. 

The  limit  to  the  dose  which  may  be  given  has  not  been  found.  The 
senior  author  in  one  case  gave  two  ounces  and  six  drachms  each  day  for 
about  ten  days.  It  is  rarely  necessary,  however,  even  in  the  most  des- 
perate cases,  to  go  higher  than  three  hundred  grains  a  day ;  and  such  a 
quantity  is  better  in  its  results  if  administered  in  six  than  in  three  doses, 
always  well  diluted  in  milk  or  aerated  mineral  water  and  put  into  the 
stomach  two  hours  after  finishing  a  meal  or  one  hour  before  taking  food. 

When  small  quantities  are  to  be  given  for  a  considerable  time,  and  the 
stomach  has  been  first  tested  with  a  solution  to  try  its  temper,  the  medi- 


256  VENEREAL  DISEASES. 

cine  may  be  given  in  pill  form  for  the  sake  of  convenience.  Tablets  of 
varied  strength  up  to  five  grains  of  the  pure  iodide  of  potassium  are  now 
found  in  the  shops  in  the  compressed  form.  They  bear  transportation 
well  if  kept  in  bottles  stoppered  with  a  cork.  To  make  up  a  pill,  how- 
ever, of  any  strength,  a  little  pepper,  gum  tragacanth,  and  glycerin  make 
excellent  excipients.  Such  a  pill  when  well  made  grows  solid,  smooth, 
and  quite  hard;  but  its  hardness  is  no  obstacle  to  its  digestion,  since  the 
affinity  of  the  iodides  for  water  is  very  great,  and  such  pills  readily  break 
up  in  the  stomach.  A  fair  formula  is  the  following: 

!£  Potassii  iodidi, 

Pulv.  pip.  nig.,    .        . 

Gum.  tragacanth., 

Glycerini, aa  q.s. 

M.  ft.  pil.  No.  xxiv. 

These  pills  are  not  unnaturally  large,  each  one  contains  five  grains  of 
the  iodide,  and  they  should  be  taken  with  or  immediately  after  each 
meal.  In  many  cases  they  do  not  disagree,  in  others  they  certainly  do. 

A  favorite  method  of  giving  the  iodides  is  in  combination  with  some 
bitter  vegetable  tincture  or  infusion,  which  serves  the  double  purpose  of 
masking  the  peculiarly  pungent,  bitter  taste  of  the  drug,  as  well  as  in  a 
measure  assisting  its  digestion.  The  taste  of  the  iodide  may  be  still  fur- 
ther covered  up  by  the  addition  of  ginger,  peppermint,  or  bitter  orange 
to  the  solutions  in  one  form  or  another,  and  the  dose  thus  made  actually 
agreeable.  Some  ammonia  may  be  added,  if  thought  best,  out  of  respect 
to  the  general  conviction  that  the  presence  of  this  drug  enhances  the  thera- 
peutical activity  of  the  iodide.  Such  a  formula  as  the  following  is  rarely 
objected  to : 

3  Potass,  iodid.,     . 3  ij. 

Ammonias  subcarb., 3  ss. 

Tr.  cinchonse  co.,        .         .         .         .        .         .         .         .    3  iv. 

Glycerini,  .        .        .         .         .         .        .  .         .    3  i. 

Syr.  aurantii  cort., §  iss. 

M.     S.  Teaspoonful  largely  diluted  with  water  after  each  meal. 

For  convenience  of  administration,  when  the  dose  of  iodide  is  to  be 
constantly  and  rapidly  pushed,  it  is  well  for  the  patient  to  have  two  pre- 
scriptions :  one  something  like  the  one  given  above,  and  another  a  satu- 
rated solution  of  the  iodide  of  potassium  in  distilled  water : 

3  Potass,  iodidi  vel.  stronttt  iodidi, 5  i. 

Aquae  destillatse, q.s.  ad  fl.  §  i. 

M. 

Of  this  solution  one  minim  measured  in  a  minim  glass  represents  a 
grain  of  the  iodide,  and  it  may  be  very  conveniently  used,  a  teaspoonful 


THE   GENERAL   TREATMENT   OF   SYPHILIS.  257 

of  the  pleasantly  tasting  mixture  being  mingled  with  water,  and  as  many 
minims  extra  of  the  saturated  solution  of  the  iodide  being  added  to  each 
dose  as  may  be  required  to  make  the  dose  of  the  iodide  sufficient,  in  cases 
in  which  this  is  varied  a  little  from  day  to  day. 

It  will  be  noticed  in  the  foregoing  prescription  that  only  enough  water 
is  ordered  to  make  an  ounce  of  fluid  in  all.  As  commonly  written  the 
prescription  reads: 

R  Potassii  iodidi, |  i. 

Aquae  destillatse, §  i. 

M. 

Such  a  formula  makes  more  than  an  ounce  of  fluid — nearly  an  ounce 
and  a  half,  in  fact — and  it  takes  about  seven  minims  to  equal  five  grains 
of  the  iodide  of  potassium. 

All  the  remarks  thus  far  made  have  referred  to  the  iodide  of  potas- 
sium, nothing  having  been  said  of  the  iodides  of  sodium  or  strontium. 
The  potassium  compound  is  the  stronger,  being  just  about  twice  as 
effective  as  the  sodium  combination.  How  much  stronger  it  is  than  the 
strontium  salt,  if  at  all  stronger,  is  not  yet  decided.  It  is  therefore  to  be 
preferred,  and  in  all  cases  should  be  commenced  with  first.  When,  after 
fair  trial  and  reasonable  effort,  it  has  become  apparent  that  the  potassium 
iodide  is  not  suitable,  and  that  the  stomach  will  not  bear  it,  then  the 
strontium  or  sodium  iodide  may  be  substituted  often  with  very  good  effect, 
since  in  this,  as  in  many  other  cases,  the  sodium  or  strontium  salt  is  more 
agreeable  to  the  stomach  than  the  potassium  salt.  All  that  has  been 
written,  therefore,  concerning  the  iodide  of  potassium  is  equally  applica- 
ble to  the  iodides  of  sodium  and  of  strontium  for  those  cases  in  which  the 
stronger  drug  is  not  well  borne. 

Mixed  Treatment. — The  mixed  treatment  is  a  combination  of  one  of 
the  iodides  with  a  mercurial.  It  is  one  of  the  commonest  forms  of  treat- 
ment, and  one  of  the  most  useful  when  intelligently  directed.  It  causes 
even  the  early  symptoms  to  disappear  more  promptly  than  if  mercury  be 
used  alone.  The  overzealous  young  practitioner,  in  his  early  efforts  to  do 
all  he  can  for  his  patient,  is  quite  apt  to  overshoot  the  mark  in  trying  to 
obtain  for  his  patient  all  the  good  possible  out  of  all  kinds  of  medicine. 
He  frequently  gives  the  mixed  treatment  (mercury  and  potash,  as  he 
commonly  calls  it,  instead  of  mercury  and  iodine,  which  it  more  properly 
is),  ordering  it  as  soon  as  he  decides  that  a  given  chancre  is  syphilitic. 

There  is  no  advantage  in  such  a  course.  Mercury  is  all-sufficient  in 
the  beginning,  and  anything  like  polypharmacy  is  of  doubtful  wisdom, 
since  the  stomach  and  its  integrity  constitute  the  sheet  anchor  of  the 
syphilitic  patient  in  the  long  run.  The  patient  may  have  much  medica- 
tion to  endure,  and  it  is  well  to  spare  him  in  the  beginning.  Many  stom- 
achs submit  to  the  prolonged  use  of  the  iodides  without  a  murmur,  for 
17 


258  VENEREAL   DISEASES. 

years;  but  there  are  others  which  gradually  fail  in  digestive  capacity,  and 
reduce  the  patient  to  a  condition  of  anaemia,  with  great  general  nervous 
irritability  and  prostration,  and  that,  too,  without  giving  rise  to  any 
marked  active  evidences  of  dyspepsia.  The  iodides,  long  continued,  are 
fully  as  liable,  or  more  liable  to  do  harm  than  the  mercurials.  It  may 
become  necessary,  during  a  prolonged  and  obstinate  attack  of  syphilis,  to 
use  not  only  the  mercurials  for  a  long  time,  but  the  iodides  also ;  and 
when  it  becomes  necessary,  let  it  be  done.  But  this  is  not  an  excuse  for 
using  the  iodides  out  of  place,  or  calling  upon  the  stomach  for  extra  work 
when  it  is  not  required. 

The  mixed  treatment  is  appropriate  in  all  the  slower,  more  chronic 
symptoms  of  the  intermediary  and  late  stages  of  syphilis.  The  basis  of 
the  treatment  is  an  appropriate  iodide,  either  of  sodium,  strontium,  or 
potassium,  as  the  case  may  be,  and  with  it  a  mercurial.  The  treatment 
may  be  effectually  carried  out  by  giving  a  suitable  dose  of  the  iodide,  as 
directed  in  the  last  section,  and  adding  the  mercury  by  fumigation,  in- 
unction, or  separately  in  pill.  It  is  a  little  more  appropriate,  however, 
and  perhaps  more  accurate  in  dosage  when  giving  the  mixed  treatment, 
to  mix  the  drugs  themselves  in  the  same  pill  or  potion.  The  best  drug 
•to  mix  with  the  iodides  is  the  biniodide  of  mercury.  Most  other  forms 
decompose,  and  the  resulting  compound  is  an  uncertain  amount  of  bin- 
iodide  of  mercury,  with  an  equally  uncertain  quantity  of  the  other  mer- 
curial, however  much  there  may  be  which  has  escaped  decomposition. 

The  biniodide  of  mercury,  therefore,  may  be  added  to  any  of  the  pills 
or  fluids  already  referred  to  in  the  section  on  the  iodides,  in  a  dose  vary- 
ing from  one-thirtieth  up  to  an  eighth  of  a  grain.  The  new  ingredient  in 
the  combination  will  make  no  difference  in  its  form  or  taste,  but  often 
makes  a  great  difference  in  its  effect  upon  the  patient. 

Some  of  the  pills  found  in  the  market  are  made  so  as  to  represent  the 
mixed  treatment,  containing  varied  proportions  of  the  iodide  of  potassium 
and  the  biniodide  of  mercury. 

In  using  the  mixed  treatment,  it  is  often  desirable  to  continue  the 
mercury  at  a  given  rate  while  the  iodide  is  steadily  pushed.  This  consti- 
tutes what  is  called  mixed  treatment  with  iodides  in  excess,  an  expression 
which  will  be  found  to  occur  several  times  in  this  book  when  speaking  of 
the  treatment  appropriate  to  some  of  the  various  lesions. 

When  to  cease  giving  the  iodides  is  a  question  of  importance.  They 
are  useful,  most  useful,  against  certain  symptoms  in  syphilis,  but  they 
cannot  claim  power  to  prevent  relapse.  Therefore  we  should  use  them, 
and  vigorously  too,  against  the  symptoms  that  they  control,  but  should 
not  depend  upon  them  for  any  more  work  after  the  symptoms  have  yield- 
ed. The  main  difficulty  in  the  case  is,  therefore,  how  to  tell  when  the 
symptoms  in  question  are  thoroughly  controlled.  A  gummatous  infil- 
trated patch  may  gradually  melt  away  under  the  bold  use  of  the  iodides, 


THE   GENERAL   TREATMENT   OP   SYPHILIS.  259 

and  seem  to  be  entirely  gone ;  yet,  if  the  iodides  be  discontinued  too  soon, 
this  patch  will  relapse  in  many  cases.  How  can  it  be,  then,  that  the 
iodides  do  not  prevent  relapse? 

The  answer  to  this  question  may  be  found  by  analogy  in  the  study  of 
other  infiltrations.  Guinmatous  processes  are  infiltrations,  and  the  terti- 
ary connective-tissue  proliferation,  the  interstitial  hypertrophy  of  organs, 
is  an  analogous  change.  These  diseased  conditions  of  the  tissues  extend 
farther  than  is  evident  to  the  naked  eye.  In  the  same  way  cancerous 
infiltrations  and  epitheliomatous  nodules  far  outreach  their  limits  as  ap- 
parent to  ordinary  inspection.  An  epithelioma  may  be  burned  upon  the 
surface,  and  the  nodule  apparently  destroyed — so  much  indeed  that 
a  thin,  unhealthy  scar  may  form  over  the  spot;  yet  the  morbid  tissue, 
although  apparently  gone,  often  remains  in  the  outlying  tissues,  and  in 
such  a  case  local  relapse  is  inevitable.  The  same  is  true  of  lupus,  and 
the  effect  of  local  applications  upon  it ;  and  of  carcinoma,  and  the  cutting 
operations  to  which  it  is  subjected. 

In  the  same  way  in  syphilitic  infiltrations  the  remedy  which  removes 
them,  the  iodic  preparations,  must  be  long  and  patiently  continued  after 
the  local  trouble  is  apparently  under  control,  or  local  relapse  is  certain. 
It  is  customary,  therefore,  to  continue  the  mixed  treatment  for  months 
after  all  evident  need  for  the  iodides  has  passed,  and  then  gradually  to 
drop  the  iodides  and  resume  the  mercurial  at  the  tonic  dose.  Eventually 
the  mercury  itself  may  be  gradually  dropped  after  a  number  of  months, 
differing  in  varying  cases,  according  to  the  judgment  of  the  physician. 

In  some  cases  of  the  old  syphilis,  especially  the  nervous  forms,  when 
the  iodides  have  been  long  given  in  large  doses,  the  symptoms  may  after 
a  time  fail  to  yield  to  the  drug,  while  the  patient  gradually  grows  thin, 
nervous  in  the  ordinary  sense  of  the  term,  tremulous  perhaps  in  his  move- 
ments, unable  to  sleep,  to  digest  food,  to  perform  mental  work.  Some- 
times in  such  cases  the  clinical  picture  suggests  the  idea  of  cerebral  soft- 
ening, yet  the  whole  may  be  due  to  long-continued  excess  in  the  use  of 
the  iodide  of  potassium.  A  cure  is  attained  by  cessation  of  the  iodic 
course,  aided  by  mental  and  bodily  rest  and  hypophosphites  with  strych- 
nine. These  are  the  patients  who  recover  sometimes  after  a  change  of 
physician,  or  after  giving  up  what  they  call  the  "  old-school "  doctor  and 
trying  homoeopathy. 

Zittmann's  Decoction: — In  terminating  the  general  remarks  upon  the 
routine  treatment  of  syphilis,  something  must  be  said  about  Zittmann's 
decoction.  This  remedy  has  long  held  a  respectable  place  in  the  minds 
of  the  profession,  and  the  formula  by  which  it  is  prepared,  in  a  stronger 
and  a  weaker  decoction,  retains  its  place  in  the  dispensatories.  It  is  a 
remedy  of  undoubted  value  in  many  conditions  of  late  syphilis  attended  by 
cachexia,  loss  of  appetite,  ansemia,  and  irritable  stomach,  especially  when 
the  iodides  disagree.  Its  action  is  probably  largely  dependent  upon  the 


260  VENEREAL  DISEASES. 

laxative  influence  of  the  senna  which  it  contains,  and  upon  the  general 
combinations  which  makes  the  mercury  in  it  Acceptable  to  the  stomach. 

There  have  always  existed  two  great  drawbacks  to  its  general  use : 
(1)  it  is  difficult  to  prepare,  containing  a  hosf-  of  ingredients  which  must 
be  so  concocted  that  much  time  is  consumed  in  their  proper  preparation ; 
and  (2)  its  use  according  to  the  rules  formerly  laid  down  is  too  irksome 
to  be  endured  by  most  patients,  while  the  quantities  necessary  to  produce 
any  effect  (a  pint  and  more  a  day)  cannot  be  conveniently  mastered  by 
many  patients  with  delicate  stomachs.  Then,  also,  the  rules  about  pre- 
paratory purgation,  rest  in  bed,  hot  water  with  one  decoction  at  one  time 
in  the  day,  and  cold  water  with  another  decoction  at  another  time  of 
day,  smack  really  more  of  the  wizard  than  of  the  sage,  and  tend  to  bring 
the  remedy  into  disrepute  with  honest-minded  persons,  lay  as  well  as 
professional. 

The  truth  is  probably  that  judicious  purgation,  with  a  light  tonic  lax- 
ative containing  a  mercurial,  and  that  too  in  fair  dose,  is  what  does  the 
good.  In  McDonnell's  lectures  on  surgery  in  1871, '  there  appeared  a 
nwdified  Zittmann's  decoction  which  did  away  with  much  of  the  apparent 
superfluity  of  the  older  preparation ;  but  even  this  is  too  clumsy,  with  its 
larger  and  smaller  dose,  and  cold  and  hot  water.  It  acts  just  as  well 
when  reduced  to  a  single  combination.  A  tablespoouf  ul  is  the  dose  taken 
without  water,  three  or  four  times  daily,  regulating  the  quantity  by  the 
purgative  effect.  The  following  is  the  formula  : 

^  Hydrarg.   chlorid.  corrosivi, gr.  i. 

Aluminis, * ' 3  ss. 

Extr.  sarsapj     .        .        .        .    • fl.  |  ij. 

Glycerin!, |  i. 

Syr.  sennse, .3  iss. 

Spts.  anis., 3  i. 

Extr.  glycyrrhizae,    .         .         .         ...         .         .    3  i. 

Aquae  fceniculi, q.s.  ad    §  viij. 

M.     S.  Tablespoon  ful  at  a  dose. 

The  treatment  of  inherited  syphilis,  and  of  syphilitic  women  during 
pregnancy,  will  be  given  under  their  own  sections. 

1  Page  114. 


CHAPTER  X. 

SYPHILIS   OF  THE   SKIN. 

THE  symptoms  upon  the  skin  and  mucous  membranes  have  always 
given  the  best  field  for  studying  syphilis ;  and  since  the  dermatologist  has 
brought  his  powers  to  bear  upon  a  study  of  the  numerous  lesions  of  the 
skin  produced  by  syphilis,  much  peculiarity  has  been  found  to  exist  in  all 
the  lesions  due  to  the  disease,  and  much  distinctiveness  in  form,  color, 
grouping,  etc.,  so  that  the  class  of  eruptions  produced  upon  the  skin  by 
syphilis,  and  known  as  syphilides,  has  become  well  established.  The 
syphilides  are  generally  capable  of  being  diagnosticated  by  the  aid  of 
simple  inspection.  Before  going  into  the  detail  of  description  of  the 
different  eruptions  it  will  be  well  to  consider  the  general  characters  which 
are  shared  by  them  in  common. 

Changes  in  the  skin  such  as  the  sallowness,  the  branny  condition,  the 
lack  of  lustre  in  early  syphilis,  the  flabbiness  in  cachexia,  the  general 
tawny  hue  often  seen  in  the  same  stage,  the  seborrhoea,  the  dryness — none 
of  these  features  found  upon  a  syphilitic  patient  differ  materially  from 
the  same  conditions  when  encountered  upon  a  patient  rendered  ill  by  the 
action  of  some  other  debilitating  cause.  They  are  not  therefore  syphi- 
litic, except  in  that  they  have  become  so  by  accident. 

The  peculiar  characters  of  syphilitic  lesions  of  the  integument — those 
which  they  possess  collectively  as  a  group  of  affections — may  be  best  stud- 
ied by  examining  them  in  detail.  They  are  polymorphism,  the  color  and 
form,  the  absence  of  subjective  symptoms  in  connection  with  them,  the 
grouping  of  the  lesions,  the,  characters  of  the  scabs  and  ulcers,  and  the  ap- 
pearance and  behavior  of  the  cicatrices. 

Polymorphism  is  quite  a  distinctive  feature  in  the  early  syphilitic  ex- 
anthemata. The  evolution  of  the  eruption  is  in  successive  crops  of  lesions, 
and  some  of  these  go  on  to  a  fuller  development  than  others ;  therefore, 
in  one  and  the  same  syphilitic  eruption,  at  almost  any  period  in  its  course, 
it  is  often  possible  to  find  the  most  varied  lesions  associated  side  by  side : 
the  macule,  the  papule,  the  vesicle,  the  pustule,  the  scale,  and  the  pig- 
ment spot. 

Polymorphism  does  occur  in  other  cutaneous  diseases,  but  it  is  so  con- 
stant in  the  syphilitic  exanthemata  as  to  be  worthy  of  special  remark. 
The  same  morbid  spot  upon  the  skin,  in  going  through  its  evolution, 
assumes  the  form  of  several  lesions ;  but  in  the  general  eruption  there  is 


262  VENEREAL  DISEASES. 

always  an  excess  of  one  lesion  or  another,  and  this  type  lesion  names  the 
eruption  (papular,  pustular,  vesicular,  etc.,  syphilide). 

Color.— The  color  of  syphilitic  eruptions  is  peculiar.  The  earlier  and 
more  acute  eruptions  are  pink  and  red,  a  color  much  like  that  seen  in 
ordinary  inflammatory  states.  As  the  freshness  dies  out  of  these  erup- 
tions, however,  they  assume  the  syphilitic  tint,  and  in  some  instances 
they  possess  it  from  the  start.  This  tint  is  simply  a  certain  lividity  min- 
gled with  red.  It  has  been  called  by  many  names,  but  that  which  suits 
it  best  is  the  raw  ham  color.  The  copper  color  is  found  to  perfection  in 
many  of  the  lesions  after  they  become  pigmented,  and  it  often  remains 
for  a  long  time  in  scars  left  by  lesions,  and  in  the  areolar  border  of  the 
latter,  but  this  term  is  less  accurate  in  expressing  the  tint  of  syphilitic 
lesions  in  their  period  of  activity. 

The  color  is  due  to  the  inflammatory  process  which  produces  and 
attends  the  lesions.  The  superficial  vessels  become  dilated,  a  certain 
amount  of  cell  infiltration  occurs,  and  the  pigment  deposits  and  shows 
through. 

This  hypersemia  and  small  amount  of  pigment  makes  the  raw  ham  color. 
It  is  rarely  absent  in  any  of  the  syphilides.  As  the  hyperaemia  subsides 
and  the  vessels  return  to  their  natural  size,  the  pigment  becomes  more  ob- 
vious, and  then  the  copper  color  appears.  Finally,  nothing  is  left  but 
pigment  in  greater  or  less  quantity,  and  the  color  may  be  that  of  bronze. 

The  pigmentation  remaining  behind  after  syphilitic  lesions  is  not 
usually  permanent.  It  clears  away  promptly  in  light  cases,  more  slowly 
in  others.  It  remains  longest  on  the  lower  extremities.  It  clears  up 
from  the1  centre  peripherally,  leaving  any  cicatricial  tissue  which  it  may 
have  involved  more  white  than  the  surrounding  skin.  Occasionally,  espe- 
cially around  a  cicatrix  in  the  lower  extremity,  it  remains  permanently. 

Form  and  Distribution. — The  earlier  eruptions  are  generalized  more  or 
less  over  the  whole  body,  each  separate  lesion  showing  a  tendency  to 
assume  the  rounded  form.  Later,  the  lesions  tend  to  cluster  and  form 
patches ;  they  are  generally  symmetrical  in  their  distribution.  The  latest 
lesions  show  little  or  no  tendency  to  symmetry,  but  preserve  in  a  marked 
degree  the  rounded  form.  Gummatous  ulcers  are  often  composed  of  the 
confluence  of  several  gummata,  and  the  borders  of  the  ulcer  consequently 
are  made  up  of  segments  of  large  circles. 

Absence  of  subjective  symptoms  is  a  marked  feature  of  syphilitic  erup- 
tions. In  nearly  every  case,  and  in  nearly  every  class  of  eruption,  from 
the  macule  to  the  most  extensive  ulcer,  there  is  customarily  an  entire 
absence  of  any  itching  or  pain.  This  rule,  like  all  others  in  syphilis,  has 
its  exceptions.  An  acute  outbreak  of  an  early  syphilide  commonly  occa- 
sions little  tingling,  but  rarely  any  itching.  Ulcers,  if  connected  with 
bone,  or  upon  the  lower  extremities,  often  pain  considerably,  sometimes 
excessively.  On  the  other  hand,  the  scrofulides,  and  many  gouty  erup- 


SYPHILIS   OF  THE  SKIN.  263 

tions,  with  most  of  the  forms  of  lupus,  are  equally  devoid  of  subjective 
symptoms,  so  that  this  peculiarity  of  syphilitic  eruptions  cannot  be 
considered  to  be  pathognomonic.  Nevertheless,  the  conspicuous  absence 
of  itching  and  pain  is  a  feature  of  great  diagnostic  value  in  connection 
•with  the  syphilides. 

The  scabs  and  ulcers  of  syphilitic  lesions  have  some  peculiarities.  The 
scabs  are  apt  to  be  thick,  rough  upon  the  surface,  set  into  the  skin  at 
their  edges,  and  adherent,  unless  undermined  with  pus.  There  is  gener- 
ally also  a  marked  greenish  tint  in  the  scabs,  whether  the  latter  are  dark 
or  light  colored.  This  green  tint  is  often  due  to  the  admixture  of  a  cer- 
tain amount  of  blood  with  the  pus  forming  the  scab.  The  ulcers  of  syph- 
ilis are  round  or  oval,  resemble  chancroidal  ulcers.  Their  borders  are 
sometimes  undermined,  but  generally  adherent.  The  floor  is  pale,  uneven, 
more  or  less  pultaceous,  the  discharge  purulent.  The  edges  are  abrupt, 
perpendicular.  The  base  may  be  either  hard  or  soft. 

The  cicatrices  of  syphilitic  lesions  are  quite  uniform  in  character. 
They  are  round,  depressed,  smooth,  thin,  and  not  adherent,  unless  lying 
over  bone.  They  are  dark  at  first,  from  the  pigment  they  contain  ;  and 
as  this  clears  off  centrally,  the  scar  grows  white  and  shining,  its  white- 
ness intensified  and  set  off  by  a  dark  frame  of  pigment. 

Types  of  Syphilides.  —  The  eruptions  found  upon  the  skin  in  secondary 
and  intermediary  (late  secondary)  syphilis  are  seven.  The  last  three 
occupy  the  border  line,  and  may,  any  of  them,  be  found  long  after  the 
patient  has  suffered  from  well-marked  tertiary  gummatous  lesions  of  bone, 
or  of  the  other  tissues.  These  three  occur  also  just  as  well  entirely  within 
the  secondary  period,  and  are  best  classed  along  with  secondary  lesions. 
These  eruptions  are  named  according  to  the  prominent  lesion  which 
characterizes  them.  They  are: 

1.  Erythematous  (roseola  or  macular). 

2.  Papular. 

3.  Pustular. 

4.  Pigmentary. 

5.  Vesicular. 

6.  Papulo-squamous. 

7.  Tubercular. 

The  lesions  belonging  to  the  tertiary  period,  all  of  which  are  prone 
to  run  on  to  ulceration,  to  destroy  tissue,  and  leave  scars,  are  three  in 
number  : 

1.  Pustulo-bullous  (rupia). 

a,  with  infiltrated  base  (ecthyma). 


2.  Pustular  syphilide:  grQups> 


3.  Gumma : 


S-   .c-n.    *.-          ( 1»  non-ulcerative. 
a.  as  infiltration:    J 
( 2,  ulcerative. 
b,  tumor. 


264  VENEREAL  DISEASES. 

In  connection  with  all  of  these  occur  lesions  on  the  mucous  mem- 
branes, which  will  be  considered  in  their  proper  place,  and  varied  gen- 
eral symptoms:  glandular  engorgement,  fever,  alopecia,  etc.,  some  of 
which  have  already  been  considered. 

Erythematous  Syphilide.— This  is  the  most  common  and  the  earliest 
of  the  general  syphilides.  It  may  come  on  within  a  month  after  the  ap- 
pearance of  chancre,  generally  six  weeks  or  two  months,  sometimes  later, 
especially  if  delayed  by  treatment.  It  first  appears  upon  the  lower  part 
of  the  thorax  in  front  and  at  the  sides,  over  the  belly,  and  in  the  flanks. 


— =^-_^^— 

Fin.  st>.— Macular  Syphilide.    (Morrow.) 

A  very  hot  bath  will  frequently  develop  it  several  days  before  its  natural 
date  of  outbreak. 

The  eruption  comes  out  as  a  series  of  roundish  and  oblong  macules, 
varying  in  diameter  from  one-eighth  to  half  an  inch,  at  first  red,  then 
tawny,  then  pigmented.  At  first  the  patches  are  flat,  then  they  often  be- 
come covered  with  minute  papular  elevations,  and  sometimes  some  of 
these  papules  go  on  to  vesiculation,  occasionally  even  to  mild  pustulation 
(although  this  is  exceptional).  The  patch,  therefore,  is  flat  or  raised,  as 
the  case  may  be.  At  first  pressure  of  the  finger  causes  the  mottling  en- 
tirely to  disappear ;  later  a  slight,  livid  staining  remains  behind  after  the 
removal  of  pressure;  finally,  when  the  spot  is  fading  and  has  become 
slightly  coppery  from  pigment,  pressure  has  no  more  effect  upon  it. 

The  spots  are  never  confluent — healthy  skin  always  exists  between  the 


SYPHILIS   OF   THE   SKIN.  265 

macules ;  but  upon  this  skin  there  may  be  found  a  few  other  lesions  some- 
times, such  as  a  papule  or  a  pustule. 

The  hands  and  face,  where  the  skin  is  tougher,  often  escape  the  erup- 
tion entirely. 

The  duration  of  roseola  is  from  a  few  days  to  six  or  eight  weeks.  It 
may  relapse.  An  annular  variety  of  large  patches  in  groups,  tending  to 
turn  into  the  scaly  form,  is  found  occasionally  at  the  end  of  the  first  year 
of  syphilis.  It  runs  a  slower  course  than  the  roseola,  occurring  soon 
after  chancre.  If  treatment  (mercurial)  has  been  commenced  before  the 
appearance  of  the  eruption,  its  outbreak  is  postponed,  and  it  may  consist 
merely  of  a  few  scattered  macules  upon  the  trunk,  requiring  some  dili- 
gence to  find  them. 

The  diagnosis  of  roseola  due  to  syphilis  is  easy.  The  erythematous 
eruptions  due  to  arsenic,  bromine,  mercury,  belladonna,  quinine,  have 
different  situations  and  groupings,  and  are  attended  either  by  internal 
fever  or  local  itching.  Copaibal  erythema  itches  badly.  Koseola  autum- 
nalis  is  attended  by  fever,  and  measles  by  its  pathognomonic  prodromes. 
The  glandular,  epitrochlear,  and  post-cervical  engorgement,  the  existence 
of  chancre  and  the  throat  symptoms  (erythema  and  mucous  patches), 
together  with  the  scabs  in  the  hair,  the  night  pains,  and  the  syphilitic 
fever,  if  present,  make  syphilitic  roseola  one  of  the'easiest  to  diagnosti- 
cate of  all  the  lesions  due  to  syphilis. 

Papular  Syphilide. — This  eruption  may  be  combined  with  a  roseola, 
or  follow  the  latter ;  or  it  may  appear  as  the  first  syphilitic  eruption.  Its 
date  of  appearance  is  therefore  about  the  same  as  that  of  roseola.  The 
papules  vary  in  size,  from  a  minute  acuminated  papule,  such  as  is  seen 
upon  the  macules  of  roseola,  to  a  broad,  flat  papule  as  large  as  a 
dime.  A  common  form  is  the  flat,  lenticular  papule,  of  about  the  size 
of  a  large  split  pea.  These  papules  are  scattered  about,  not  grouped, 
occupy  the  flanks,  the  trunk,  the  extremities,  and  very  often  the  face 
(Fig.  87). 

The  characteristic  flat  papule  commences  small,  and  grows  in  all  direc- 
tions except  in  height.  It  is  hard  and  smooth  upon  its  surface  at  first, 
later  it  is  sometimes  slightly  depressed  centrally.  It  is  pink  or  red  at 
the  commencement,  but  very  soon  takes  on  the  syphilitic  livid  tint.  It 
sheds  its  epithelium  on  top,  or  the  latter  dries  down  quite  early  and 
cracks  around  the  circumference  of  the  papule.  The  broken,  rough  edge 
of  the  thickened  epidermis  then  curls  away,  like  a  dirty  lace  collar,  from 
the  base  of  the  flattened  papule,  giving  the  lesion  a  very  characteristic 
appearance.  The  papules  gradually  sink  away,  leaving  pigmented  spots, 
but  no  scars.  They  come  out  successively,  and  may  be  found  in  different 
stages  of  development  upon  different  parts  of  tho  skin. 

On  the  palm  of  the  hand  the  papules  seem  to  abort,  on  account  of  the 
thickness  of  the  scarf  skin.  A  thickening  of  the  scarf  skin  seems  to  take 


266  VENEREAL   DISEASES. 

place,  of  the  size  of  a  papule  (papulo-squamous)  (Fig.  88).  Then  the  epi- 
thelium gets  yellow  and  dry,  cracks,  and  drops  out,  leaving  a  clean-cut, 
punched-out  circle  in  the  palm,  of  the  size  of  a  split-pea,  with  a  pink,  soft, 
dry  floor,  covered  with  thin  epithelium  and  an  undermined,  whitened 
border  of  thick,  raised  epithelium,  surrounded  often  by  a  red  areola. 


FIG.  87.— Papular  Syphilide. 


These  spots  often  get  well  without  spreading,  thus  differing  from  the  later 
scaly  syphilide  of  the  palm.  Sometimes,  however,  these  spots  are  attended 
by  fissuring  and  undermining  of  the  epidermis  laterally,  and  several  spots 
may  coalesce.  This  is  not  the  rule,  but  exceptional. 

There  is  a  large,  flat  form  of  papular  syphilide  sometimes  encountered 
upon  the  body,  but  most  apt  to  be  found  upon  the  face  and  scalp.  The 
papules  are  as  large  as  the  finger  or  thumb  nail.  In  the  scalp  they  itch. 
They  are  of  a  pale  pink  color,  desquamate  readily.  Around  their  edge 


SYPHILIS   OF   THE   SKIN. 


267 


the  epidermis  gets  raised  by  a  slight  effusion  of  serum,  while  the  adher- 
ent cuticle,  bound  down  centrally  in  the  large  lesion,  gives  the  whole  an 
appearance  of  umbilication  which  is  characteristic. 

A  flat,  livid  papule,  sometimes  excoriated,  sometimes  dry,  is  occa- 
sionally found  indifferently  situated  upon  the  skin. 

When  papules  lie  in  creases  in  the  skin,  so  that  they  are  constantly 
covered  by  other  portions  of  integument  (under  the  breast  in  the  female, 
in  the  groin  in  fat  persons),  and  are 
thus  kept  warm  and  subject  to  fric- 
tion, they  are  apt  to  become  very 
large  and  flat.  They  sometimes  run 
together  into  patches  and  become 
moist  on  the  surface.  They  may 
become  exuberant  and  granulate. 
Under  these  circumstances  the 
papule  becomes  the  mucous  patch 
of  the  skin  —  the  flat  condyloma. 
They  are  common  about  the  anus, 
the  scrotum,  the  labia  (Fig.  89). 
The  gray  pellicle  upon  the  surface 
of  these  lesions  recalls  the  typical 
mucous  patch  of  the  mucous  mem- 
branes very  exactly.  The  true 
mucous  patch  of  mucous  membranes 
is  indeed  a  papule,  and  the  papule 
on  the  skin  is  customarily  associ- 
ated with  the  mucous  patch  upon 
the  mucous  membranes. 

The  duration  of  the  papular 
syphilide  is  very  variable.  It  may 
come  out  as  the  first  eruption, 
either  alone  or  mixed  with  the 
roseola,  and  continue  for  a  period 
varying  from  a  few  weeks  to  many  months.  When  apparently  getting 
well,  it  sometimes  suddenly  relapses  without  apparent  cause.  The  lesions 
on  the  palms  and  soles,  especially  if  they  run  together  into  patches,  are 
particularly  obstinate. 

Syphilitic  papules,  unless  they  ulcerate,  leave  no  scars.  The  pigment 
slowly  disappears  with  time,  sometimes  centrifugally,  leaving  a  pigmented 
margin,  which  may  persist  long  after  the  centre  has  become  whiter  than 
the  surrounding  skin. 

The  diagnosis  of  papular  syphilide  is  very  easy  in  typical  cases,  espe- 
cially if  the  eruption  is  copious,  and  other  concomitant  signs  of  early 
syphilis  are  present.  Difficulties  may  arise,  however,  when  there  are 


FIG.  88.— Papulo-Squamous  Syphilide  of  Palm. 
Early  stage. 


268 


VENEREAL  DISEASES. 


only  a  few  papules.  A  few  acuminated  papules  can  with  difficulty, 
if  at  all,  be  distinguished  from  indolent  papules  of  acne,  found  after 
middle  life  in  gouty  people  of  dark  complexion.  The  pigmented  area 
surrounding  the  site  of  a  papule  which  has  run  its  course  is  suggestive, 
but  not  pathognomonic,  of  syphilis.  In  some  cases  the  result  of  treat- 
ment alone  will  justify  a  diagnosis. 

Flat  papules,  when  occurring  in  an  isolated  way,  late  in  syphilis,  are 
also  indistinguishable  from  similar  isolated  accidental  lesions,  due  to 
indifferent  causes,  upon  rheumatic  subjects.  Treatment  here  again  be- 
comes the  most  valuable  aid  to  diagnosis,  or,  better  still,  observation, 


FIG.  89.— Flat  Raised  Papules  around  Anus.    (Condyloma  lata.) 

since  isolated  syphilitic  papules  do  not  reproduce  themselves  indefinitely, 
while  upon  certain  gouty  subjects  they  recur  from  time  to  time  with  rea- 
sonable regularity. 

Lichen  planus,  of  all  eruptions,  is  with  the  most  difficulty  differenti- 
ated from  a  papular  syphilide.  The  color  is  identical,  and  many  other 
features  are  the  same.  The  most  positive  distinguishing  marks  are  the 
umbilication  of  many  of  the  solid  papules  of  lichen  planus,  their  wide 
difference  in  size,  their  very  marked  tendency  to  run  into  patches,  and 
their  tendency  to  arrange  themselves  in  lines  with  healthy  skin  between 
the  different  lesions  rather  than  in  circles,  as  is  the  case  in  syphilitic  dis- 
ease. Moreover,  with  lichen  planus  there  are  no  concomitant  symptoms 
of  syphilis  found  in  the  lymphatic  glands  or  on  the  mucous  membranes, 
which  could  hardly  be  the  case  in  an  eruption  of  syphilitic  papules  of  like 
intensity.  The  palms  and  soles  are  much  more  apt  to  be  spared  in  lichen 
planus  than  in  a  syphilitic  papular  eruption. 

The  flat  raised  papule  (condyloma  lata)  generally  accompanies  other 
syphilitic  lesions,  and  is  relatively  easy  of  diagnosis.  When  seen  alone 


SYPHILIS   OF   THE   SKIN.  269 

about  the  anus,  a  doubt  sometimes  arises  as  to  whether  the  lesions  may 
not  be  the  ordinary  vegetations,  the  so-called  venereal  warts,  which  are 
apt  to  be  found  in  connection  with  gonorrhoeal,  leucorrhoeal,  and  other 
discharges — indeed,  complicating  all  manner  of  uncleanness. 

The  venereal  wart  is  more  uneven  on  the  surface  than  the  condyloma 
lata,  more  split  up  and  segmented  into  pointed  papillae,  like  the  ordinary 
"  seed  wart. "  A  large  cluster  of  them  may  grow  off  from  the  skin  in  a 
pedunculated  manner.  Their  color  is  apt  to  be  more  brilliant  than  that 
of  the  syphilitic  papule,  and  their  situation  is  less  frequently  the  anus  or 
scrotum.  They  lie  most  often  within  the  ostium  vaginae  in  the  female; 
under  the  foreskin  in  the  male. 

Pustular  Syphilide. — The  pustules  of  early  syphilis  are  found  in  two 
varieties:  (1)  small,  scattered,  ov  grouped,  arising  within  a  follicle,  or 
occurring  independently  upon  an  intervening  portion  of  skin;  (2)  upon 
an  inflamed  base,  but  still  superficial,  not  gummatous  (superficial  ec- 
thyma) . 

The  small  pustule  has  no  very  distinctive  marking.  It  is  apt  to  be 
generalized  over  the  whole  body  in  early  syphilis. 

The  pustular  syphilide  may  come  on  as  the  earliest  eruption  at  six 
weeks,  but  it  does  not  usually  appear  before  as  many  months.  The  scat- 
tered pustules  found  among  a  number  of  vesicles,  papules,  and  erythema- 
tous  spots  in  the  polymorphism  of  the  first  eruption  do  not  constitute  a 
pustular  syphilide.  In  the  latter  the  type  lesion  is  the  pustule,  grouped 
or  discrete.  The  lesions  are  found  scattered  over  the  whole  body,  in  the 
scalp,  upon  the  face,  upon  the  fingers  and  palms,  over  the  whole  trunk 
and  extremities.  They  vary  greatly  in  size,  take  severally  from  one  to 
three  weeks  to  reach  perfection,  and  then  they  usually  break  and  scab,  or 
dry  down  and  heal  up  under  the  little  crust.  When  they  run  together 
into  superficial  patches,  they  behave  in  much  the  same  way. 

When  the  dried-up  scabs  fall  away  the  livid  thickening  of  the  skin 
remains  for  a  considerable  period  marking  the  sites  of  the  lesions. 
These  livid  papules  (for  such  they  are)  may  be  marked  by  a  central  de- 
pression— the  hole  left  by  the  suppurated  follicle — if  the  pustule  has  been 
pierced  by  a  hair ;  or  they  may  remain  ulcerated  on  top  for  a  time,  finally 
yielding  a  thin,  white,  round  scar.  A  ring  of  pigment  around  each  sepa- 
rate healing  lesion  in  pustular  syphilis  is  rather  the  rule  than  the  excep- 
tion ;  but  the  pigment  finally  disappears,  and  the  scars  are  often  so  faint 
that  it  becomes  hard  to  detect  even  traces  of  them  in  later  years.  Groups 
of  superficial  pustules  are  much  more  rare  than  numbers  of  discrete  pus- 
tules. 

The  pustular  syphilide  is  slow.  Crops  of  pustules  come  out  at  differ- 
ent times,  relapses  are  not  uncommon ;  and,  unless  treatment  aided  by 
tonics  shortens  the  duration  of  the  affection,  it  is  apt  to  drag  itself  along 
during  several  mouths. 


270 


VENEREAL  DISEASES. 


The  diagnosis  of  superficial  pustular  syphilide  is  generally  easy  from 
the  concomitant  symptoms  and  history.  Iritis  is  apt  to  complicate  it. 
The  bronzed  areola  of  the  subsiding  lesion  is  a  great  help  to  diagnosis. 
A  generalized,  pustular,  superficial,  discrete  eruption  is  very  rarely  due 
to  any  other  cause  than  syphilis,  and  the  appearance  of  such  an  eruption 
should  immediately  suggest  an  inquiry  into  the  patient's  previous  history. 

The  superficial  ecthymatous 
syphilide  is  a  little  deeper,  a 
little  more  intense,  being  more 
deeply  seated  than  the  simple 
early  pustular  syphilide.  It  in- 
dicates that  the  patient  has  a 
bad  type  of  syphilis,  especially 
if  it  comes  on  early.  It  gener- 
ally appears  as  late  as  during 
the  second  year — late  enough  to 
be  called  tertiary;  but  in  bad 
cases  it  often  comes  on  early, 
within  a  few  weeks  of  chancre, 
and  it  leaves  a  faint  scar,  not 
indicating  any  considerable  de- 
struction of  tissue.  Occasion- 
ally, on  the  other  hand,  it  accom- 
panies early  malignant  lesions 
in  very  bad  syphilis,  and  destroys 
considerable  tissue,  which  of 
course  necessitates  a  deep  scar. 

This  syphilide  starts  as  an  in- 
filtration of  a  limited  area  of  skin 

capped  by  a  pustule,  or  of  a  patch  of  skin  upon  which  several  pustules  ap- 
pear, at  first  discrete,  later  confluent.  These  pustules  are  generally  large 
and  flattened ;  they  may  even  be  umbilicated.  The  pustules  develop  rather 
slowly,  with  little  or  no  pain,  and  finally  scab,  an  ulcer  existing  under 
the  scab  for  some  time  after  the  latter  has  formed.  The  pigmented  areola 
comes  on  during  the  latter  part  of  the  development  of  the  pustules.  The 
scar  remains  long  purple,  often  raised  and  thick,  generally  pigmented, 
and  sometimes  pitted.  Finally  the  scars  become  perfectly  white,  more 
slowly  upon  the  lower  than  upon  the  upper  extremities. 

The  diagnosis  of  this  form  of  syphilis  is  not  difficult  except  in  occa- 
sional cases  in  which,  as  sometimes  occurs,  fever  runs  high  with  the  first 
outbreak  of  the  pustules,  and  in  which  umbilication  is  marked.  A  mistake 
has  been  often  made  in  such  cases,  and  the  patient  has  been  sent  to  a 
smallpox  hospital.  The  mistake  may  be  avoided  by  noticing  the  more 
sluggish  development  of  the  syphilitic  pustules  in  crops,  the  absence  of 


FIG.  90.— Pustular  Syphilide,  Shovviug  both  Types. 


SYPHILIS   OF   THE   SKIN.  271 

intense  pain  in  the  back,  the  history  of  the  case,  and  the  concomitance 
of  other  (mouth  and  glandular)  evidences  of  syphilis. 

The  superficial  ecthyma  of  early  syphilis  differs  from  the  deep  ecthyma 
of  late  syphilis,  in  that  the  latter  is  a  guminatous  infiltration  of  the  true 
skin,  has  a  livid,  hard  base,  and  always  leaves  a  depressed,  round,  white, 
thin,  smooth,  uupitted  scar. 

Pigmentary  Syphilide. — This  eruption,  the  very  existence  of  which 
is  questioned  by  some  authors,  while  its  syphilitic  character  is  doubted 
by  many  who  acknowledge  its  existence,  was  first  accurately  described 
by  Hardy,  later  by  Foumier. 

This  syphilide  is  simply  a  coloration  of  the  integument,  varying  from 
a  light  dirty  brown  color  to  almost  a  black,  a  mottling  formed  of  patches, 
light  and  dark.  The  light  areas  of  skin  are  sometimes  of  a  natural  hue, 
sometimes  whiter  than  the  original  integument. 

The  eruption  is  generally  found  upon  the  sides  of  the  neck,  in  front 
and  on  the  upper  part  of  the  chest ;  exceptionally  elsewhere,  as  upon  the 
trunk,  the  hands.  It  is  generally  ignored  by  the  patient,  and  often  dis- 
covered only  through  accident  by  the  physician,  or  after  careful  search. 

The  lesion  has  been  considered  to  be  the  lesion  left  behind  by  a  rose- 
ola, and  at  best  it  is  an  obscure  affection  of  but  little  moment.  As  cor- 
roborative of  past  syphilis,  it  may  be  of  some  value.  It  comes  on  any- 
where in  the  second  half  of  the  first  year  after  chancre,  and  may  last 
many  months,  but  it  always  finally  disappears.  It  is  totally  devoid  of 
any  subjective  symptoms,  and  absolutely  uninfluenced  by  treatment.  It 
cannot  possibly  be  mistaken  for  anything  except  dirt,  pityriasis  versi- 
color,  freckles,  or  leucoderma.  The  first  of  these  washes  off;  the  second 
itches  faintly,  is  a  little  branny,  and  furnishes  spores  for  microscopic  di- 
agnosis ;  the  third  are  more  yellow,  and  never  confined  to  the  limited 
region  of  the  sides  of  the  neck  and  upper  part  of  the  chest.  Leucoderma 
of  the  commun  sort  has  a  different  distribution. 

Vesicular  Syphilide. — This  eruption  is  rare.  Its  date  of  appearance 
is  late  in  the  secondary  period,  generally  during  the  second  year  after 
chancre. 

The  vesicles  may  be  of  varied  size,  but  generally  are  small,  acuminated, 
scattered  about  the  trunk  and  extremities  (the  face  being  spared),  or  clus- 
tered into  groups  in  circles,  or  segments  of  circles,  upon  a  livid  base  of 
characteristic  syphilitic  color.  Each  of  the  lesions  may  be  surrounded  by 
an  areola,  at  first  livid,  then  coppery,  and  the  vesicles  may  dry  up  and 
scale,  or  become  purulent  and  scab  over. 

There  is  a  form  of  vesicular  syphilide  coming  on  earlier  (within  six 
months  after  chancre),  the  vesicles  being  large,  umbilicated,  upon  a  red- 
dened base,  with  an  areola  at  first  livid,  then  coppery.  The  vesicles 
quickly  become  purulent. 

All  the  vesicular  syphilides  are  slow  in  evolution  and  apt  to  be  pro- 


272  VENEREAL  DISEASES. 

longed  by  successive  outcrops  of  new  vesicles  and  clusters  of  vesicles  con- 
tinuing to  appear  as  the  first  dry  up.  The  livid  spots  left  by  the  vesicles 
gradually  whiten  and  leave  either  no  scar  or  pitted  cicatrices. 

The  diagnosis  is  easy.  The  umbilicated  vesicle  may  suggest  vari- 
cella, but  there  is  no  itching  except  in  the  scalp,  and  other  syphilitic 
lesions  are  apt  to  accompany  this  umbilicated  form  of  the  eruption.  The 
generalized  vesicular  syphilide  does  not  become  confluent  and  yield  an 
oozing  surface  as  does  eczema.  The  color,  the  areola,  the  grouping,  the 
absence  of  itching,  distinguish  it  easily  from  other  vesicular  eruptions. 

Papulo-Squamous  Syphilide. — The  papulo-squamous  syphilide  occurs 
toward  the  end  of  the  first  year  of  syphilis,  or  at  any  period  later.  It  may 
come  on  long  after  the  tertiary  stage  has  set  in,  after  gummata  have  ap- 
peared, after  bone  disease  has  been  inaugurated  and  cured.  Long  after 
the  patient  thinks  himself  well,  several  years  perhaps  after  the  appear- 
ance of  any  symptom  due  to  syphilis,  an  elevated  patch  of  squamous  syphi- 
lide may  appear  upon  the  face  and  be  improperly  called  a  lupus  by  the 
physician — or  a  circinate  scaly  eruption  comes  out  upon  the  scrotum  and 
here  the  patient  looks  upon  it  as  a  ringworm. 

Solid  patches  of  papulo-squamous  syphilide  may  occur  upon  the  face 
or  any  part  of  the  body.  The  skin  is  thickened,  more  or  less  livid,  often 
not  distinctly  papulated,  but  infiltrated.  The  size  and  shape  of  the 
patches  vary  greatly,  from  small  dots  to  broad,  rounded  sweeps  of  erup- 
tion. The  livid  surface  is  covered  with  fine  white  scales,  which  are 
tightly  adherent.  These  scales  shed  off  and  are  replaced  by  new  crops, 
until  finally  the  infiltration  disappears  and  the  patch  gets  well,  leaving 
no  scar.  If  the  patch  has  been  positively  tuberculated  as  well  as  scaly, 
round  scars,  not  much  if  at  all  pigmented,  are  apt  to  be  scattered  over 
the  livid  scaly  area  covered  by  the  eruption,  and  these  scars  remain  per- 
manent after  the  affection  gets  well. 

The  circinate  form  may  come  on  early  or  very  late  in  syphilis,  attack- 
ing any  part  of  the  body,  but  most  common  upon  the  scrotum,  or  about 
the  genitals,  in  either  sex.  The  circle,  or  segment  of  a  circle,  starts 
of  a  given  size,  and  does  not  increase  like  ringworm.  A  number  of  seg- 
ments of  circles  often  run  into  each  other,  making  a  festooned,  gyrate 
figure.  The  border  of  the  circle  forming  the  eruption  varies  in  breadth 
up  to  about  a  quarter  of  an  inch  j  generally  it  is  but  little  wider  than  an 
eighth  of  an  inch  on  the  scrotum.  The  skin  enclosed  by  the  segments 
of  circles  remains  sound.  The  border  of  the  circle  is  generally  distinctly 
papulated,  some  of  the  papules  being  dry,  some  moist,  some  scaly,  some 
scabbed.  About  the  genitals  patients  sometimes  assert  that  the  eruption 
itches. 

Diagnosis.—  Coincident  symptoms  of  syphilis,  and  the  history,  to- 
gether with  the  common  situation  along  the  roots  of  the  hair  on  the  fore- 
head, about  the  genitals,  etc.,  help  to  make  a  diagnosis  which  the  effect 


SYPHILIS   OF  THE   SKIN. 


273 


of  treatment  will  promptly  justify  if  it  has  been  accurate.     In  color,  on 
the  other  hand,  and  general  arrangement,   patches  of  papulo-squamous 


FIG.  91.—  Papulo-Squamous  Syphilide.    (Morrow.) 

syphilide  are  sometimes  quite  indistinguishable  from  some  forms  of  pso- 
riasis, and  a  localized  patch  on  the  face  is  sometimes  nearly  enough  like 
erythematous  lupus  to  deceive  a  practitioner  not  expert  in  the  differential 
18 


274 


VENEREAL  DISEASES. 


diagnosis  of  skin  diseases.  The  circinate,  scaly  syphilide  cannot  long  be 
mistaken  for  ringworm,  since  in  syphilis  the  circle  does  not  grow  by  cen- 
trifugal enlargement. 

The  palmar  and  plantar  papulo-squamous  syphilides  are  lesions  of  the 
first  importance  in  connection  with  syphilis.  There  are  several  varieties 
of  this  eruption.  One  of  them  has  already  been  described,  namely,  the 
round,  livid,  dry  spots  on  the  palm,  looking  as  if  a  piece  of  the  epithelial 
layer  had  been  cut  out  with  'a  punch,  and  the  borders  of  the  scarfskin 


FIG.  93.— Palmar  Papulo-Squamous  Syphilide.    Advanced  stage.    (After  Kaposi,  Morrow.) 

afterward  slightly  undermined  (Fig.  92).  Besides  these  spots,  which  are 
best  observed  in  connection  with  a  generalized  papular  syphilide,  other 
rounded  and  oblong  scaly  patches  of  the  palm  and  sole  are  encountered  in 
syphilis  at  almost  every  stage  of  the  disease. 

These  are,  with  few  exceptions,  round  and  oval.  The  different  lesions 
commence  as  livid,  red  areas,  or  as  round,  epidermal  patches  of  a  yellow 
color,  according  as  hypersemia  of  the  surface  vessels  or  cellular  infiltration 
is  the  more  pronounced  pathological  process.  As  the  lesion  progresses  it 
spreads  centrifugally,  the  epidermis  fissures  and  scales  off,  and  the  differ- 


SYPHILIS   OF   THE   SKIN.  275 

ent  lesions  run  into  each  other,  making  a  large  patch  with  irregular, 
rounded  border  (Fig.  92).  The  centrifugal  spread  of  the  patches  leaves 
a  livid,  pink  centre,  free  from  any  special  lesion  other  than  hyperaemia. 
In  the  natural  furrows  of  the  palm  or  sole,  and  at  their  border,  deep  fissures 
are  apt  to  form  in  the  edges  of  the  eruption.  Friction  upon  the  palm,  as 
in  rowing,  using  tools,  etc.,  is  an  active,  exciting  cause;  much  walking 
and  ill-fitting  shoes  act  in  the  same  way  upon  the  sole.  Elevated  livid 
tubercles,  more  or  less  scaly,  also  occur  in  patches  upon  the  palm. 

Symmetry  is  not  the  rule  in  either  palmar  or  plantar  syphilis. 

Diagnosis. — Some  forms  of  lichen  urticatus,  of  eczema,  and  of  pso- 
riasis resemble  it  very  closely.  In  the  first  and  last  of  these  affections, 
however,  the  plantar  or  palmar  lesion  is  never  found  alone.  The  charac- 
ter of  general  eruption  upon  the  rest  of  the  body,  therefore,  clears  up  all 
doubt  concerning  the  lesion  in  question.  An  eczematous  patch,  however, 
may  be  found  exclusively  confined  to  the  palm.  It  is  apt  to  itch,  it  is 
thinner  at  the  edge,  shades  off  into  the  surrounding  integument  more  than 
the  syphilide  does.  It  is  not  so  livid  in  color,  and  has  no  purple  border, 
as  is  sometimes  the  case  in  the  syphilide.  Eczema  is  more  irregular,  less 
rounded  in  outline,  much  more  chronic  in  duration,  as  a  rule,  and  apt  to 
extend  out  over  the  palm  upon  the  softer  skin  around. 

Tubercular  Syphilide. — This  syphilide  occurs  in  two  forms — genera- 
lized, or  in  groups.  The  generalized  form  is  quite  unusual,  that  in  groups 
very  common.  The  former  rarely  occurs  before  the  second  half  of  the 
first  year  from  chancre ;  the  latter  quite  exceptionally  before  the  second 
year.  Isolated  patches  of  tubercle  may  come  on  at  any  date,  many  years 
after  all  traces  of  the  disease  have  disappeared. 

The  general  tubercular  syphilide  is  not  the  papular  syphilide  in  which 
the  papules  are  large.  It  develops  deeply  down  in  the  tissue  or  the  true 
skin  beneath  the  papillary  layer.  It  is  not  a  gummy  tumor  of  the  sub- 
cutaneous tissue.  When  it  occurs  as  a  generalized  eruption,  it  does  so  as 
an  eruption  of  patches  and  groups  of  clustered  lesions  in  circles  and  seg- 
ments of  circles.  Some  of  the  patches  are  the  result  of  a  confluence  of 
many  tubercles,  and  then  the  patch  is  a  solid  livid  elevation  of  the  skin, 
uneven  on  the  top,  and  covered  with  scales.  Each  separate  lesion,  if  it 
stands  alone,  is  livid  in  hue,  capped  with  a  scale  or  a  small  pustule,  and 
often  surrounded  by  a  livid  areola,  afterward  becoming  coppery.  The 
different  tubercles  vary  in  size  from  a  grain  of  rice  to  a  good-sized  pea, 
and  they  usually  leave  a  cicatrix  when  they  disappear,  whether  their  sur- 
face has  been  ulcerated  or  not.  The  scar  is  at  first  livid,  then  often  pig- 
mented,  then  white,  round,  thin,  smooth,  depressed,  not  at  all  retractile. 

The  diagnosis  ia  easy.  It  is  hard  to  imagine  an  eruption  with  which 
the  tubercular  syphilide  could  be  confounded. 

The  tuberculo-squamous  or  tuberculo-ulcerated  syphilide  in  groups  is  a 
late  lesion.  It  is,  indeed,  positively  tertiary,  but  often  occurs  upon  the 


276 


VENEREAL,   DISEASES. 


border-line.  The  face  is  a  favorite  seat  of  the  eruption,  but  it  may  occupy 
any  part  of  the  body.  Livid  patches  of  thickened  skin  constitute  the 
eruption. 

Scales  upon  these  patches  are  quite  obvious,  but  the  tubercles  may  be 


FIG.  93.— Tubercular  Syphllide.    (Morrow.) 


scarcely  so,  perhaps  not  visible  at  all.  Sometimes  the  only  reason  one 
has  to  call  the  affection  tuberculo-squamous  is  the  existence  of  round, 
white,  depressed  scars  upon  the  surface  in  among  the  scales,  of  the  size 
of  a  pea,  marking  the  site  of  tubercular  infiltrations  of  the  true  skin,  the 


SYPHILIS   OF   THE    SKIN.  277 

interstitial  absorption  of  which  has  produced  the  white  scars.  Generally 
the  tubercles  are  quite  plainly  visible  upon  the  surface.  Sometimes  they 
stand  apart,  sometimes  they  run  together  and  enclose  areas  of  healthy 
skin  within  raised  circular  borders. 

The  evolution  of  the  patch  is  by  the  circumferential  growth  of  new- 
tubercles.  Those  first  formed  disappear,  leaving  scars  without  previously 
ulcerating,  and  upon  the  old  spots  where  former  tubercles  have  flourished 
and  gone  away  new  ones  may  crop  out  later  and  go  slowly  through  their 
changes,  leaving  scars  behind.  Eingworm  may  be  simulated  by  circinate 
patches  of  tuberculo-squamous  disease. 

This  syphilide  is  maintained  by  the  successive  outcrop  of  new  tuber- 
cles, and  a  single  patch  may  thus  be  prolonged  for  years.  Sometimes  the 
infiltration  which  forms  the  tubercle  goes  on  so  rapidly  that  the  integrity 
of  the  integument  is  compromised,  ulceration  takes  place,  and  a  serpigi- 
nous  ulcer  results,  as  after  the  pustular  syphilide  in  groups. 

The  diagnosis  of  tubercular  syphilide  in  groups  is  very  easy  if  atten- 
tion be  paid  to  the  central  cicatrices  in  the  patch.  These  are  round, 
white,  smooth,  and  not  puckered.  In  tubercular  non-ulcerative  lupus 
this  quality  of  scar  is  not  observed,  the  cicatrix  being  puckered  and 
linear.  This  feature  alone  is  all  that  is  required  to  make  a  distinction. 
The  lividity  of  color  is  much  more  marked  in  syphilis  than  in  lupus. 

TEKTIARY  SYPHILIDES. 

The  final  three  sets  of  eruptions  to  be  considered — rupia,  ulcerative 
syphilis,  and  gurnina — are  strictly  tertiary.  They  all  occur  habitually  in 
the  second  year  of  the  disease  and  later,  and  they  uniformly  and  inevitably 
destroy  the  structure  of  the  true  skin  and  leave  scars.  Treatment  post- 
pones their  outbreak,  or  may  prevent  them  from  appearing  at  all. 

Eruptions  of  this  kind  may  be  ushered  in  while  the  patient  is  enjoy- 
ing apparently  the  most  flourishing  health.  They  are  all  painless,  unless 
they  involve  a  bone  or  joint,  as  well  as  the  integument.  Sometimes 
they  accompany  the  profound  cachexia  produced  by  syphilis;  but  the 
same  cutaneous  lesions  may  be  found  upon  patients  who  present  no  evi- 
dences of  cachexia  whatsoever.  Rupia,  however,  whether  the  patient 
shows  cachexia  or  not,  indicates  a  very  bad  quality  of  constitution. 

Pustulo-Bullous  Syphilide  (Rupia). — Rupia  sometimes  starts  as  a  flat 
pustule,  sometimes  as  a  bulla.  The  patient  may  look  fat  and  seem  healthy, 
but  he  is  not  so,  or  he  would  not  have  rupia.  If  a  bulla  first  forms,  it 
runs  on  quickly  to  suppuration,  and  blood  becomes  mingled  with  the  pus. 
The  first  lesion  thus  formed  scabs  over,  and  under  the  scab  ulceration 
commences,  yielding  pus,  which  raises  the  scab  from  its  bed.  Meantime 
around  the  scab  first  formed  an  epidermal  raised  ring  appears,  filled  with 
sero-pus.  This  dries  down  into  a  blackish-green  scab,  enlarging  the  first 


278 


VENEREAL   DISEASES. 


crust,  while  ulceration  goes  011  beneath  the  whole.  A  new  sero-purulent 
subepidermal  collar  forms  again  around  the  lesion,  and  the  process  goes 
on  repeating  itself. 

The  new  layers  of  pus  supplied  from  beneath  raise  and  thicken  the 
scab,  and  if  this  prbcess  continues  long  without  much  increase  in  the  area 


FIG.  94.— Rupial  Syphilide. 

of  the  patch  by  the  formation  of  circumferential  bullse,  as  may  be  the  case, 
a  horn  may  be  formed  sometimes  an  inch  long  or  more,  and  in  any  case 
the  roughened  crust  comes  to  bear  a  close  resemblance  to  an  oyster  shell, 
and  pressure  upon  it  generally  causes  pus  to  ooze  out  at  one  of  the  edges 
of  the  sore.  If  the  scab  gets  detached  another  may  form,  or  the  lesion 


SYPHILIS   OP   THE   SKIN. 


279 


may  progress  as  an  open  or  a  partly  scabbed  ulcer,  with  a  livid  or  pulta- 
ceous  base  and  sharp-cut  borders.  Sometimes  cicatrization  goes  on  under 
the  scab,  which  finally  falls  off,  leaving  a  livid  cicatrix,  generally  covered 
with  ridges,  drawn  and  puckered  in  part,  sometimes  surrounded  by  a  cop- 
pery areola,  sometimes  having  only  a  livid  border.  In  almost  all  cases 
the  scars  eventually  become  white. 

Tertiary  Pustular  Syphilide. — In  tertiary  disease  the  pustular  syphi- 
lide  is  found  in  two  forms.     As  a  puslule  with  an  infiltrated  base,  ec- 
thyma,  and  as  a  patch   of  pustules 
beneath  which  destructive  ulceration 
goes  on. 

The  deep  ecthyuiatous  pustule  is 
a  general  gummy  infiltration  of  the 
skin,  capped  with  a  pustule,  which 
usually  goes  on  to  ulceration. 

The  gummatous  thickening  of 
the  skin  is  obvious  in  the  case  of 
single  isolated  ecthymatous  lesions, 
but  it  becomes  lost  as  the  single 
lesion  ulcerates  or  the  patch  of 
ecthymatous  pustules  spreads. 
When  this  thickening  is  present  it 
exists  as  a  lurid,  painless,  hard  lump, 
often  surrounded  by  a  bronzed  areola, 
especially  upon  the  lower  extremity, 
as  the  isolated  ecthymatous  spot  gets 
old. 

The  thick  green  crust  which 
forms  upon  the  top  of  an  ecthyma- 
tous pustule  resembles  a  rupial  crust. 
Its  edges  are  thin,  and  frequently 
are  depressed  beneath  the  level  of 
the  surrounding  skin,  making  the 
latter  look  like  a  setting  which  holds 

the  scab  in  place.  These  scabs  are  quite  adherent,  and  may  remain  at- 
tached until  cicatrization  is  complete  (Fig.  95). 

The  cicatrix  of  a  single  deep  ecthymatous  spot  is  the  typical  syphilitic 
scar,  smooth,  thin,  white,  depressed,  non-adherent.  At  first  it  is  livid, 
and  it  remains  in  most  cases  surrounded  for  a  long  time  by  a  border  of 
pigment. 

The  favorite  seat  of  deep  ecthyma  is  the  lower  extremities  —  but 
it  may  be  found  anywhere  upon  the  body,  and  is  not  uncommon  on  the 
face. 

When  several  ecthymatous  lesions  run  together,  an  ulcer  may  result, 


FIG.  95.— Tertiary  Pustular  Syphilide. 


280 


VENEREAL   DISEASES. 


which  may  become  serpiginous,  and  creep  over  a  considerable  extent  of 
surface,  often  getting  well  on  one  side  as  it  advances  toward  the  other 

(Fig.  96). 

Ecthyma  does  not  necessarily  indicate  a  bad  condition  of  the  patient. 

The  pustular  syphilide  in  groups  generally  comes  on  late  in  syphilis. 
A  red  spot  appears,  which   quickly  becomes   covered  with  small   pus- 


FiG.  96.— Ulcerous  Syphilide. 

tules.  These  run  together  and  scab,  and  beneath  the  scab  ulceration  goes 
on.  As  the  ulcer  grows,  so  does  the  scab,  and  if  the  latter  falls  off  or 
is  removed,  a  new  one  forms.  The  secretion  beneath  the  scab  is  scanty, 
and  the  crust,  therefore,  does  not  become  rupial. 

Finally,  when  the  patch  has  reached  a  considerable  size  in  some  cases, 
the  new  pustules  around  the  edges  upon  the  livid  areola  cease  to  form, 


SYPHILIS   OF   THE   SKIN. 


281 


the  whole  patch  dries  up  and  contracts,  cicatrizing  under  the  crust. 
When  the  latter  falls,  a  livid  scar  is  left,  with  a  bronzed  areola.  The 
centre  whitens,  the  areola  generally,  but  not  always,  disappears. 

A  serpiginous  ulcer  may  result  from  this  lesion,  as  it  may  from 
ecthyma,  or  from  rupia. 

An  error  in.  diagnosis  is  not  probable.  The  pustular  scrofulide  gen- 
erally comes  early  in  life,  and  the  lesion  with  its  ulcer  has  different 
characters. 


I 


FIG.  97.— Tertiary  Syphilitic  Ulceration. 

The  syphilitic  tertiary  ulcer  is  not  an  especial  affection.  It  is  a  second 
stage  of  rupia,  ecthyma,  patches  of  tubercles,  or  of  pustules,  or  a  sequence 
of  gummy  infiltration,  or  of  gummy  tumor  of  the  skin. 

The  ulcer  always  has  similar  characters,  whether  destroying  in  depth 
or  running  superficially  upon  the  surface  (serpiginous  ulcer).  The  ulcer 
has  perpendicular  edges,  hard,  livid  (generally) ,  adherent  borders,  a  livid, 
pultaceous  floor  (sometimes  smooth  and  shining),  and  often  a  hard  base. 
These  lesions  are  painless  for  the  most  part,  unless  they  involve  the  peri- 
osteum from  being  situated  over  it,  as  on  the  shin,  or  unless  they  become 
inflamed  from  injury,  or  by  position,  as  on  the  lower  extremity. 


282 


VENEREAL  DISEASES. 


The  syphilitic  ulcer  may  remain  stationary,  it  may  eat  downward, 
exposing  a  bone,  destroying  the  periosteum,  and  leaving  a  piece  of  bare 
bone  in  the  floor  of  the  ulcer.  This  bone,  at  first  white,  becomes  black. 
It  often  dies,  gradually  separates  from  the  healthy  bone  beneath,  and  is 
thrown  off.  The  deep,  destructive  ulceration  which  deforms  the  nose 
generally  follows  a  gummy  tumor  or  gummatous 
infiltration.  The  same  may  be  said  of  the  de- 
structive ulcer  of  the  penis. 

Serpiginous  ulcers  are  those  which  spread 
superficially,  either  in  all  directions  or,  advancing 
in  one  direction,  get  well  in  the  other. 

Great  care  must  be  exercised  to  distinguish  a 
tertiary  ulcer  upon  the  tongue  or  lip  from  an  epi- 
thelioma,  upon  the  penis  from  a  phagedenic  chan- 
croid or  an  epithelioma, 
upon  the  nose  or  face  from 
an  ulcerative  lupus  or  a 
rodent  ulcer.  The  pecul- 
iar characters  of  syphi- 
litic ulcers,  so  often  al- 
ready detailed,  ought  to 
be  sufficient  to  guide  to  a 
diagnosis  in  most  cases. 

In  all  cases  of  doubt  the  touchstone  of  treatment,  if  intelligently  applied, 
will  clear  up  the  question  promptly. 

Gumma  of  the  Skin. — Tubercular  and  ecthymatous  patches  are  cer- 
tainly the  seat  of  gummatous  infiltration.  There  is  also  a  true  gumma 
of  the  skin,  which  appears  as  a  general  infiltration,  and  another  form 
which  takes  the  shape  of  a  circumscribed  tumor.  Either  form  may  ulcer- 
ate ;  the  latter  habitually  does  so  unless  arrested  by  treatment. 

Diffuse  gummatous  infiltration  of  the  skin  is  not  common.  It  occurs 
as  a  patch  of  livid  redness,  hard,  raised,  somewhat  scaly  on  the  surface, 
perhaps  for  a  long  time  smooth  and  shining.  Upon  this  surface  little 
prominences  may  appear,  which  quickly  ulcerate.  The  ulcers  run  together 
and  behave  like  the  syphilitic  ulcers  already  described,  remaining  sta- 
tionary or  becoming  serpiginous,  but  not  destroying  in  depth.  Rarely 
the  patch  sinks  away,  leaving  a  general  thinning  of  the  skin  behind,  but 
no  distinct  scar  as  such. 

Gummatous  infiltration  of  the  skin  presumably  precedes  all  ulceration 
of  the  serpiginous  sort,  whether  coming  on  as  a  sequence  to  rupia,  ecthyma, 
or  any  other  lesion ;  and  the  infiltrated  patches  bearing  tubercles,  scales, 
or  pustules  owe  their  infiltration  undoubtedly  to  an  analogous  patholog- 
ical condition. 

The  gumma  proper  of  the  skin  is,  strictly  speaking,  the  syphilitic 


FIG.  98.— Tertiary  Syphilitic  Ulceration  of  the  Arm. 


SYPHILIS  OF   THE   SKIN.  283 

tubercle.  The  gummy  tumor,  yielding  an  ulcer  on  the  skin,  is  generally 
a  localized  accumulation  of  gummatous  cells  in  the  subcutaneous  connec- 
tive tissue.  These  are  first  noticed  as  hard,  shot-like  bodies  beneath  the 
skin.  They  are  absolutely  insensitive  upon  manipulation.  The  skin  is 
freely  movable  over  them,  and  they  themselves  are  not  attached  firmly  to 
the  surrounding  or  underlying  parts.  In  this  state  a  subcutaneous  gumma 
may  remain  for  months,  and  sometimes  gradually  disappear  even  without 
treatment,  leaving  no  apparent  trace  of  its  former  existence.  Generally, 
however,  unless  treatment  intervenes,  the  lump  gradually  enlarges,  at- 
taches itself  to  all  surrounding  tissues,  softens  centrally,  and  the  detritus 
of  gummy  matter  slowly  but  surely  ulcerates  its  way  to  the  surface. 

The  skin  over  the  tumor  in  such  a  case  becomes  livid  and  thin,  the 
soft  central  spot  finally  gives  way,  and  the  contents  of  the  tumor  escape. 
This  detritus  is  composed  of  broken-down  gummatous  cells,  and  the  de- 
bris of  the  intervening  tissue  which  was  infiltrated  with  those  cells. 
After  discharging,  the  gumma  remains  open  as  a  deep  syphilitic  ulcer. 

Gummata  of  the  nose  are  very  apt  to  lead  to  perforation,  destruction 
of  bone,  and  permanent  deformity.  Gummata  occur  over  the  whole 
body.  Local  traumatisms  seem  sometimes  to  call  them  into  existence. 

Wherever  the  gumma  occurs,  the  tissue  which  is  implicated  is  certain 
to  be  destroyed.  The  remains  of  the  solid  parts  may  become  cretaceous 
and  encysted,  and  continue  in  this  state  indefinitely.  Sometimes  gumma- 
tous exudation  is  entirely  absorbed,  leaving  behind  a  cyst  containing  a 
little  fluid.  This  termination  is  exceedingly  rare. 

The  treatment  of  syphilides  of  the  skin  is  that  of  the  stage  in  which 
they  occur.  Local  measures  are  unnecessary  in  some  and  very  useful  in 
other  instances.  Their  consideration  is  taken  up  in  the  section  on  general 
treatment. 


CHAPTER   XL 

SYPHILIS  OF  MUCOUS  MEMBRANES,  LYMPHATIC   GLANDS, 
HAIRY  PARTS,  AND  NAILS. 

THE  mucous  membranes  of  the  body,  as  well  as  the  outside  integu- 
ment, are  affected  by  various  lesions  iu  the  course  of  syphilitic  disease. 
These  lesions  are  few  in  number.  Some  of  them  occur  early,  some  late 
in  the  disease,  others  at  all  times.  They  are,  in  the  mouth,  throat,  and 
nose: 

1.  Erythematous  patches  with  erosions  and  superficial  ulcers  (occur- 
ring at  all  times). 

2.  Mucous  patches  (occurring  in  the  typical  form  only  during  secon- 
dary syphilis). 

3.  Scaly  patches  (occurring  only  late  in  syphilis) . 

4.  Gummatous  ulcers  (occurring  only  late  in  syphilis). 

Erythematous  Patches,  Erosions,  and  Superficial  Ulcers. — These  le- 
sions, most  notable  during  the  earliest  general  outbreak  of  syphilis,  may 
yet  appear  in  modified  form  throughout  the  disease,  either  in  connection 
with  the  various  eruptions  or  independently.  Often,  during  the  syphi- 
litic fever,  when  the  lymphatic  glands  behind  the  neck  just  begin  to  be 
perceptible,  careful  inspection  will  show  that  the  fauces  are  covered  with 
a  uniform  redness,  suggestive  of  a  common  sore  throat.  This  redness 
may  extend  out  of  sight  up  into  the  nares  and  down  below  the  pharynx. 

With  this  erythema  the  patient  generally  complains  of  more  or  less 
pain,  and  he  may  be  temporarily  deaf,  or  lose  his  voice  for  a  few  days. 

In  connection  with  this  redness,  excoriations  may  occur  upon  the  lips, 
upon  the  throat,  along  the  edges,  upon  the  dorsum,  and  at  the  tip  of  the 
tongue. 

Peculiarly  common  after  the  lapse  of  several  years  is  an  angry  red- 
dened excoriation  of  the  sides  of  the  tongue,  far  back  near  the  root,  on 
both  sides.  This  may  exist  for  months  without  ulcer  or  scaly  patch.  It 
is  kept  up  by  smoking,  and  by  rough  edges  of  teeth,  but  occasionally 
occurs  without  the  aid  of  either  of  these  exciting  causes. 

Mucous  Patches. — The  typical  mucous  patch  is  a  lesion  found  only  in 
syphilis  and  in  perfection,  usually,  only  in  early  syphilis.  It  may  come 
on  simultaneously  with  the  first  erythema  of  the  throat,  and  continue  to 
appear  from  time  to  time  throughout  the  secondary  period;  but  it  is  com- 
monly seen  in  greatest  perfection  in  connection  with  the  general  papular 
syphilide  of  the  integument.  The  forms  occurring  late  in  the  secondary 


SYPHILIS   OP  MUCOUS   MEMBRANES.  285 

and  during  the  tertiary  period  are  usually  scaly  patches  and  excoriations, 
resembling  the  squamous  syphilide  more  than  the  papule.  The  true  mu- 
cous patch  is  a  flat  papule  with  a  sodden  epithelium  capping  it.  Its  con- 
nection with  the  papule  has  been  touched  upon  in  the  description  of  the 
flat  papular  syphilide,  where  it  was  shown  how  any  flat  syphilitic  papule, 
kept  moist  and  sodden,  becomes  a  mucous  papule  of  the  skin. 

Clinically  speaking,  the  mucous  patches  are  round,  or  irregularly 
rounded,  raised  patches  of  a  dirty  white  color,  sometimes  red  and  granu- 
lating, covered  with  a  more  or  less  puriform  secretion.  In  size,  they 
vary  from  a  point  to  large,  irregular  surfaces,  generally  produced  by  the 
confluence  of  several  patches,  and  capable  of  reaching  almost  any  dimen- 
sions. They  occur  about  the  tonsils,  and  upon  all  the  pharynx,  within 
the  lips,  or  upon  the  tongue,  within  the  nose,  and  down  in  the  larynx 
and  trachea,  where  they  have  been  repeatedly  observed  with  the  laryngo- 
scope. Unless  ulcerated  or  attended  by  surrounding  erythema,  they  are 
painless.  Often  the  patient  is  unconscious  of  their  existence.  When  they 
ulcerate  or  inflame,  they  may  become  quite  painful. 

They  relapse  frequently,  and  continue  to  come  out  upon  the  mucous 
membranes,  either  spontaneously,  or,  more  often,  as  the  result  of  local 
irritation — a  rough  tooth,  smoking. 

Mucous  patches  do  not  leave  any  scars  unless  they  ulcerate,  and  even 
then,  the  ulceration  being  superficial,  the  scars  are  not  well  marked. 

Scaly  patches  upon  the  throat,  tongue,  and  the  inside  of  the  lips  and 
cheeks  are  very  common  during  the  second  year  of  syphilis  and  later. 
They  take  the  place  of  mucous  patches,  and  are  frequently  called  by  that 
name.  They  may  occur  early  enough  in  syphilis  to  be  associated  with 
the  true  mucous  patch,  but  their  natural  position  is  later  in  the  disease. 

They  appear  as  flat,  rounded,  irregularly  shaped  patches  of  a  bluish- 
white  color  anywhere  within  the  mouth,  but  by  preference  at  the  angles 
of  the  lips,  and  on  the  tip,  sides,  and  dorsum  of  the  tongue.  They  are 
quite  flat  and  insignificant-16oking.  They  are  manifestly  due  to  epithelial 
thickening,  and  their  whiteness  depends  upon  this  fact.  Sometimes  a 
limited  patch  (particularly  under  the  tongue)  will  take  on  extensive  over- 
growth and  yield  an  adherent  white  patch  of  epithelium  as  thick  as  a 
piece  of  blotting-paper.  Sometimes  these  occur  also  in  the  angles  of  the 
mouth.  Sometimes  the  entire  dorsum  of  the  tongue  becomes  covered 
with  this  scaly  syphilide,  giving  it  a  mottled  white  and  blue-white  appear- 
ance. 

These  patches  cannot  be  scraped  off.  They  fire  not  ulcers.  If  roughly 
handled  they  bleed.  They  are  generally  sensitive,  although  not  seemingly 
inflamed,  and  when  large  patches  exist  in  the  mouth  the  contact  of  condi- 
ments causes  pain,  and  eating  is  accomplished  only  at  the  expense  of  great 
discomfort.  Occasionally  they  ulcerate,  but  this  is  not  the  rule.  They 
occur  also  in  the  vulva. 


286  VENEREAL   DISEASES. 

Smoking,  chewing  tobacco,  all  irritants  applied  to  the  mouth,  the 
rough  edges  of  teeth,  lack  of  cleanliness,  are  exciting  causes  of  the  scaly 
syphilide  of  the  mouth. 

These  patches  sometimes  closely  resemble  true  ichthyosis  of  the  tongue. 

The  mingled  excoriations  and  scaly  patches  found  not  infrequently 
upon  the  tongue  and  in  the  mouth  of  persons  having  a  tendency  to  dry 
eczema,  once  seen,  could  not  be  mistaken  for  a  scaly  syphilide. 

Gummatous  Ulcers  of  the  Mouth  and  Fauces. — Besides  the  slight  round 
ulcers  and  the  irregular  erosions  of  the  mouth  common  to  the  whole  period 
of  syphilis,  three  other  forms  of  ulcer  occur,  namely :  the  stationary, 
chronic,  infiltrated  ulcer ;  the  serpiginous  ulcer ;  and  the  ulcerative  gummy 
tumor.  All  of  these  occur  late  in  syphilis.  The  infiltrated  ulcer  is  also 
found  early  in  the  disease. 

The  deep,  ragged,  brawny  ulcer  of  the  tonsil,  found  in  syphilis,  may  be 
encountered  early  and  late  in  the  disease,  alone  and  coincidently  with 
other  symptoms.  This  ulcer  occupies  the  tonsil  by  preference,  usually  is 
oval,  with  its  long  axis  parallel  to  that  of  the  tonsil.  It  may  extend  over 
upon  either  of  the  half  arches,  or  upon  the  soft  palate.  It  may  indeed 
occur  spontaneously  at  the  angles  of  the  mouth,  inside  the  cheeks,  or 
elsewhere.  The  base  is  pultaceous,  the  borders  are  cut  away,  generally 
livid,  sometimes  pink,  usually  hard  and  accompanied  by  a  sodden,  livid 
condition  of  cedernatous  infiltration  of  all  the  surrounding  tissues. 

The  ulcer  remains  stationary  or  progresses  slowly.  It  often  occasions 
great  pain,  especially  upon  swallowing.  But  little  tissue  is  destroyed, 
and  the  resulting  scars  are  not  deep. 

The  serpiginous  ulcer  occurs  later  in  the  disease,  and  is  manifestly  a 
gummatous  infiltration.  The  seat  of  these  ulcers  is  varied.  The  edge,  or 
the  upper  part  of  the  soft  palate,  is  not  infrequently  involved,  and  quite 
often  the  back  of  the  pharynx.  More  rarely  other  parts  of  the  mouth  are 
affected.  Not  infrequently,  with  this  form  of  ulcer  in  the  pharynx,  the 
larynx  is  the  seat  of  tertiary  syphilitic  disease. 

These  tertiary,  serpiginous  ulcers  sometimes  remain  stationary  for 
months,  even  years,  upon  the  pharynx,  giving  very  little  pain. 

Sometimes  they  advance  rapidly,  eating  off  the  uvula  in  a  few  days, 
and  destroying  large  portions  of  the  soft  palate  by  eating  it  away  from 
the  edge  inward.  When  such  ulcers  get  well  they  occasionally  leave  the 
pharynx  much  distorted  by  cicatrices. 

The  gummy,  stationary,  or  serpiginous  ulcer  of  the  pharynx  generally 
goes  with  a  bad  type  of  disease,  and  is  often  associated  with  profound 
syphilitic  cachexia. 

Gummy  tumors  may  appear  anywhere  within  the  mouth.  Gumma  of 
the  tongue  will  be  described  under  the  head  of  syphilis  of  the  digestive 
organs.  The  gumma  of  the  hard  or  soft  palate  is  not  uncommon,  and  is 
very  dangerous  on  account  of  the  damage  it  is  likely  to  cause  if  unchecked. 


SYPHILIS   OF   THE   LYMPHATIC   GLANDS.  287 

A  submucous,  round,  insensitive  swelling  first  appears,  not  attended 
by  pain.  Perhaps  the  gummatous  infiltration  is  diffuse  over  a  limited 
area,  and  not  concentrated  into  a  single  nodule.  The  growth  of  the  gum- 
matous material  may  be  slow  at  first,  but  it  is  often  rapid  from  the  start. 

When  the  tumor  has  reached  a  certain  size,  the  mucous  membrane  over 
it  becomes  oedematous  and  rapidly  gives  way,  disclosing  a  cavity  which 
constitutes  a  gummatous  ulcer  like  that  seen  upon  the  skin,  with  perpen- 
dicular edges  and  a  deeply  situated  grayish-yellow  floor.  The  diffuse 
infiltration  in  a  similar  manner  may  soften  suddenly,  and  rapid  ulcera- 
tion  sweep  away  quite  an  expanse  of  tissue. 

Extensive  destruction  of  tissue  may  ensue  unless  treatment  intervene, 
and  large  portions  of  the  roof  of  the  mouth  may  be  sacrificed  to  obscurity 
of  diagnosis  or  lack  of  therapeutical  boldness. 

As  a  prophylactic  measure  against  syphilitic  lesions  in  the  mouth  all 
possible  sources  of  irritation  should  be  avoided,  and  strict  cleanliness 
should  be  observed.  For  the  mild  and  simple  lesions  the  general  internal 
treatment  of  the  disease  may  be  all  that  is  required. 

As  regards  smoking,  it  need  not  be  discontinued  except  in  individual 
cases  in  which  it  proves  a  source  of  irritation. 

In  the  more  severe  lesions  smoking  should  be  prohibited,  a  daily  mouth 
wash  of  mild  corrosive  sublimate  (1:4,000-6,000)  or  some  active  deter- 
gent (borolyptol)  should  be  ordered  and  the  internal  treatment  judiciously 
pushed.  Sluggish  ulcerations  are  assisted  toward  healing  by  the  applica- 
tion of  a  strong  solution  of  nitrate  of  silver  or  the  acid  nitrate  of  mercury. 
The  general  treatment  is  considered  under  that  heading. 

Late  manifestations  of  syphilis  in  the  mouth  call  for  a  vigorous  course 
of  the  iodides. 

SYPHILIS  OF  THE  LYMPHATIC  GLAKDS. 

As  has  already  been  stated,  the  lymphatic  glands  receiving  the  absorb- 
ents from  the  region  occupied  by  the  initial  lesion  of  syphilis  undergo 
indolent  engorgement.  Then  follows  a  rest  (second  incubation  period), 
and  then  general  syphilis. 

At  the  commencement  of  general  syphilis,  Xisually  before  the  outcrop 
of  any  general  eruption,  certain  glands  become  indolently  engorged  and 
constitute  valuable  corroborative  evidence  of  the  syphilitic  nature  of  any 
other  symptom  which  may  subsequently  appear. 

The  glands  which  are  of  clinical  value  in  the  diagnosis  of  general 
syphilis  are  the  epitrochlear  and  the  posterior  superficial  chain  of  the 
post-cervical  glands,  especially  the  highest  two  of  the  chain,  those  lying 
oil  the  occipital  bone,  one  on  either  side  of  the  nucha.  The  post-aural 
glands  are  also  often  involved,  the  lateral  glands  in  the  neck,  and  the  axil- 
lary glands. 

The  glands  become  as  hard  as  bullets,  freely  movable  in  all  directions, 


288  VENEREAL   DISEASES. 

and  not  adherent  to  the  skin.  The  integument  over  them  is  not  colored, 
and  they  are  insensitive  to  pressure,  with  occasional  exceptions,  when  they 
first  come  out.  They  rarely  get  larger  than  a  good-sized  pea. 

The  duration  of  these  glandular  indurations  is  quite  protracted.  They 
appear  about  six  weeks  after  chancre,  and  habitually  last  for  months — 
but  little,  if  at  all,  affected  by  treatment.  They  generally  disappear  dur- 
ing the  first  year. 

Other  glandular  lymphatic  engorgements  do  occur  constantly  in  syph- 
ilis in  various  regions.  In  connection  with  mouth  lesions,  or  spontane- 
ously, one  or  more  glands  of  the  neck  indifferently  situated  may  suddenly 
swell  up,  remain  enlarged  for  a  long  time,  perhaps  finally  suppurating, 
or  abscess  may  promptly  form  in  a  gland,  running  on  to  a  speedy  open- 
ing and  discharge. 

Sometimes  these  glandular  enlargements  reach  a  great  size,  soften, 
but  fail  to  discharge,  and,  not  being  opened,  their  contents  dry  up  and 
are  absorbed,  a  caseous,  cretified  mass  being  left  behind. 

These  same  changes  in  the  lymphatic  glands  may  occur  in  the  groin, 
axilla,  and  elsewhere,  but  are  most  common  in  the  neck. 

Finally,  tertiary  gummata  are  encountered  in  various  glands,  internal 
as  well  as  external,  which  may  ulcerate  externally,  forming  gummatous 
ulcers,  and  may  disappear  by  absorption,  especially  in  response  to  treat- 
ment. The  abdominal  glands  will  be  referred  to  again  in  connection  with 
visceral  syphilis,  and  the  consideration  of  syphilis  of  the  spleen  and  of 
the  suprarenal  capsules  will  be  more  appropriate  there. 

SYPHILIS  OF  THE  HAIR  AND  NAILS. 

The  alopecia  of  syphilis  is  a  feature  of  early  secondary  disease,  very 
often  observed  in  connection  with  syphilitic  fever  and  with  the  first  erup- 
tion. It  varies  greatly  in  degree,  being  generally  quite  moderate  and 
confined  to  the  scalp,  from  which  it  thins  out  the  hairs  to  a  greater  or 
less  extent,  while  occasionally  it  is  very  severe,  implicates  the  whole 
body,  and  perhaps  causes  the  shedding  of  all  the  hairs. 

This  shedding  of  the  hair  in  early  syphilis  is  a  mere  accident,  and 
not  intrinsically  a  syphilitic  symptom.  It  is  the  result  of  the  anaemia  of 
early  syphilis,  and  is  due  to  a  failure  of  a  full  supply  of  nutrition  to  the 
hair  papillae.  This  loss  of  hair  is  never  permanent  when  occurring  in  a 
young  person. 

Later  in  syphilis  from  cachexia,  there  may  be  a  similar  thinning  of 
the  hair,  and  in  these  cases  the  hair  is  less  apt  to  grow  again. 

Finally,  in  cases  of  ulcerative  disease,  involving  the  hair  papillae  and 
destroying  them,  localized  areas  of  baldness  ensue,  which  are  necessarily 
perpetual. 

The  treatment  of  syphilitic  alopecia  is  a  general  treatment  of  syphilis 


SYPHILIS   OF  THE   HAIR  AND   NAILS.  289 

— the  treatment  of  that  stage  in  which  the  alopecia  occurs.  There  is 
much  value  in  mercury  both  as  a  preventive  to  the  fall  of  hair,  and  to 
arrest  the  fall  after  it  has  commenced  in  the  alopecia  of  early  syphilis. 
The  cachectic  form  occurring  later  generally  calls  for  mixed  treatment 
combined  with  tonics. 

The  patient  should  be  told  to  wash  his  scalp  thoroughly  once  or  twice 
a  week,  either  with  tar  soap  or  with  borax  3  i.  to  the  f  ij.  of  hot  water, 
or  with  liquor  ammoniae,  a  drachm  to  the  pint  of  hot  water,  according  to 
the  dirtiness  of  the  scalp  and  the  amount  of  seborrhoeal  exudation  which 
it  is  desired  to  remove.  Bather  hard  brushing  with  moderately  stiff 
brushes  is  to  be  recommended. 

Finally,  a  stimulating  lotion  should  be  rubbed  every  night,  in  small 
quantities,  well  upon  the  scalp,  and  into  the  follicles  under  the  hair. 
Such  lotions  add  a  little  to  the  chance  of  preserving  the  vitality  of  some 
of  the  hairs  whose  life  is  only  threatened,  and  encourage  the  growth  of 
the  new  hair.  The  following  are  good  lotions : 

1$  Chloral,  hydrat.,   .......  3  iss.-iij. 

Tr.  capsici, 3  vi.-xiv. 

Glycerini, .  3  ij- 

Spts.  myrcise,        ......     q.s.  ad  §  vi. 

M. 

Instead  of  the  glycerin  and  bay  rum,  oil  of  sweet  almonds  with 
cologne  water  may  be  preferred,  as  below ;  it  is  slightly  more  stimulating, 
and  leaves  the  hair  softer  and  less  sticky. 

E  Tr.  cantharidis, 3  iiss.-iv. 

Ol.  amygdal.  dulcis,      .         .         .         .         .         .  3  ij- 

Aquae  cologniensis, q.s.  ad  §  iij. 

M. 

Syphilis  of  the  nails  and  of  the  hair  are  somewhat  analogous.  If  the 
early  eruptions  are  intense  the  nails  are  likely  to  get  thin  and  lose  their 
lustre,  to  show  more  white  dots  than  usual,  and  to  become  more  brittle 
and  liable  to  crack.  Later  in  the  disease,  when  the  matrix  of  the  nail  is 
more  positively  influenced  by  the  disease,  all  of  these  changes  may  be 
more  marked,  constituting  a  true  dry  onychia. 

In  onychia  the  nail  first  thins  behind  at  the  base.  As  it  grows  for- 
ward, ridges  and  furrows  are  seen  upon  it,  parallel  at  first,  and  then  con- 
verging. The  nail,  in  this  way,  gets  dry,  brittle.  It  looks  dirty  and 
cracks  easily,  and  is  thin,  wavy,  and  irregular  from  lunula  to  tip.  This 
form  of  onychia  is  rare,  but  less  rare  than  another  form,  in  which,  instead 
of  thinning,  the  nail  ceases  to  grow  entirely,  its  tip  continues  to  grow 
forward,  but  its  posterior  edge  terminates  abruptly  in  a  free,  jagged  mar- 
gin. In  this  manner  the  whole  nail  may  grow  off  and  be  shed.  A  new 
nail,  perhaps  normal,  possibly  distorted  in  various  ways,  ultimately  is 
produced  to  take  the  place  of  the  lost  nail. 
19 


290  VENEREAL  DISEASES. 

A  more  common  form  of  dry,  syphilitic  onychia  than  either  of  the 
above  is  that  in  which  the  nail,  usually  first  at  one  side  of  the  forward 
edge,  becomes  thickened  (hypertrophio  onychia),  friable,  crumbly,  of  a 
dirty,  yellowish-white  color.  The  whole  thickened  surface  of  the  altered 
part  of  the  nail  cracks,  fissures,  and  splits  away  in  pieces,  until  a  portion 
of  the  matrix  at  the  side  has  been  left  dry  and  bare.  Sometimes  a  por- 
tion only  of  the  nail,  sometimes  the  whole  nail,  is  involved  in  this  proc- 
ess. The  nail  which  is  finally  reproduced  is  nearly  always  normal  in 
structure  and  appearance. 

All  the  forms  of  onychia  which  have  been  described  are  dry  and  pain- 
less. The  patient  usually  ascribes  them  to  an  injury,  but  they  are  not 
infrequently  symmetrical  on  both  hands.  They  always  get  well  with  or 
without  treatment,  and  their  course  is  invariably  very  slow. 

Treatment.  — Internal  mercurial  treatment  certainly  modifies  dry  onych- 
ia favorably ;  but  the  effect  of  treatment  is  slow.  The  five  or  ten  per 
cent  oleate  of  mercury  may  be  anointed  upon  the  dry,  rough  nail  at  night, 
and  the  parts  protected  by  a  glove  finger.  Iodides  do  not  exercise  so 
favorable  an  influence  upon  dry  onychia  as  mercurials,  bvit,  as  the  affec- 
tion often  comes  on  at  the  end  of  the  second  year  or  later,  the  combina- 
tion of  some  form  of  iodine  with  the  mercurial  administered  internally 
is  not  inappropriate. 

Perionychia  due  to  syphilis  is  somewhat  more  comnton  than  onychia, 
and  may  be  ulcerative  or  non-ulcerative.  A  mucous  patch  may  appear 
under  the  nail  or  alongside,  and,  ulcerating,  involve  the  matrix.  Ulcer- 
ative and  papulo-squamous  lesions  may  grow  up  to  the  border  of  the  nail, 
and  include  the  matrix  in  a  fissure  or  an  ulcer.  An  ulcer  preceded  by  a 
small,  painful,  livid  swelling  may  start  at  one  side  of  the  nail,  and  run 
around  the  border,  involving  the  nail,  and  causing  it  to  be  shed  by  sup- 
puration of  the  matrix.  Such  ulcers  are  apt  to  be  attended  by  the  forma- 
tion of  exuberant  granulations  at  the  borders  of  the  undermined  nail. 
The  secretions  are  retained  in  such  cases  long  enough  to  putrefy  and  be- 
come offensive  in  odor.  The  whole  or  only  a  portion  of  the  nail  may 
come  away,  and  the  ulcer  which  takes  its  place  may  eat  down  into  the 
matrix  deeply  enough  to  destroy  it.  The  whole  toe  or  finger  may  in- 
flame (dactylitis),  and  the  ungual  phalanx  may  be  involved  in  necrosis. 
When  the  ulcer  is  deep  enough  to  involve  the  matrix  to  a  considerable 
extent,  a  healthy  nail  is  not  again  produced,  but,  after  healing,  which 
always  takes  place,  the  nail  may  be  represented  by  a  deformed  substi- 
tute, or  by  uneven  bands  of  cicatricial  tissue  containing  varied  amounts  of 
nail  substance.  A  gummy  tumor  commencing  in  the  matrix  sometimes 
occurs,  terminating  in  ulceration,  sweeping  away  the  nail,  and  threaten- 
ing the  whole  phalanx. 

The  diagnosis  of  syphilitic  onychia  and  perionychia  is  difficult.  The 
onychia  in  its  different  forms  is,  in  many  cases,  difficult  to  distinguish 


SYPHILIS   OF  THE   NAILS.  291 

from  similar  conditions  produced  by  eczema  and  psoriasis.  The  ulcera- 
tive  form  resembles  ingrowing  nail,  but  in  the  syphilitic  disease  the  ma- 
trix is  usually  involved  first,  and  not  secondarily,  as  in  ordinary  ingrow- 
ing nail,  or  in  common  "  runaround."  The  gummy  tumor  is  not  apt  to  be 
taken  for  anything  else. 

The  treatment  of  perionychia,  and  of  ulcerated  matrix  generally,  is  to 
keep  the  parts  scrupulously  clean  by  washing  with  warm  water  and  green 
soap,  by  means  of  a  camel' s-hair  brush ;  to  remove  all  dead  and  raised  por- 
tions of  nail  (often,  with  advantage,  the  whole  nail),  and  to  treat  the  stage 
of  syphilis  in  which  the  malady  occurs  with  the  remedies  appropriate  to 
that  stage.  The  best  local  applications  for  the  ulcers  are  iodoform,  noso- 
phen,  or  glutol  freely  used,  black  and  yellow  wash,  and  the  judicious  use 
of  poulticing,  pressure,  and  nitrate  of  silver  if  the  granulations  are  exu- 
berant. 


CHAPTER  XII. 

SYPHILIS    OF    MUSCLES,    TENDONS     AND     APONEUKOSES, 
BURS.E,    JOINTS  AND  BONES. 

SYPHILIS  attacks  the  muscles  by  involving  their  cellular  tissue  in 
hyperaemic  and  hyperplastic  changes,  or  by  the  formation  of  gummatous 
nodules.  The  function  of  the  muscle  is  always  interfered  with  while 
under  the  influence  of  the  attack.  The  diffuse  hyperplastic  form  tends 
to  produce  atrophy ;  the  gumma  destroys  the  part  of  the  muscle  it  occupies. 

Hypercemic  myositis  may  be,  and  doubtless  is,  a  mild  degree  of  the 
diffuse  hyperplastic  form. 

The  malady  in  question  appears  to  involve  mainly  the  lower  end  of 
the  biceps  cubiti.  Other  muscles  also  suffer — notably  the  triceps  in  the 
arm.  The  malady  comes  on  between  the  sixth  and  the  tenth  months, 
oftener  in  light  than  in  severe  syphilis,  and  usually  in  patients  who  have 
suffered  from  pains  in  the  muscles  and  fibrous  tissues  previously  in  the 
disease.  Usually  the  affection  is  unilateral,  or,  if  bilateral,  of  unequal 
intensity  on  the  two  sides. 

It  comes  on  insidiously,  and  advances  slowly.  Attempts  to  move 
the  affected  muscle  cause  pain.  When  the  biceps  alone  is  attacked  there 
is  inability  to  straighten  the  arm  completely  on  account  of  contraction  of 
the  painful  muscle.  The  tendon  at  the  elbow  feels  prominent  and  tense. 
When  the  triceps  is  simultaneously  involved  there  is  muscular  ankylosis. 

Untreated,  this  affection  continues  for  several  months — occasionally 
several  years — but  gets  well  eventually,  without  altering  the  muscular 
structure. 

The  diffuse  form  of  connective-tissue  hyperplasia  is  a  chronic  myositis 
of  specific  nature.  The  substance  of  the  muscle  becomes  thickened  by 
the  development  of  new  cells,  which  go  on  to  organization  into  fibres, 
contract  like  all  cicatricial  tissue  upon  the  muscular  elements,  and  in  the 
end  lead  to  atrophy  of  the  muscle,  with  more  or  less  shortening  and  loss 
of  function. 

In  this  affection  there  is  no  pain,  but  the  muscle  gradually  shortens, 
diminishes  in  size,  and  becomes  more  fibrous  in  texture. 

Treatment  is  of  advantage  in  some  cases,  even  after  atrophy  has  com- 
menced. All  cases  treated  early  are  favorably  influenced  by  a  combina- 
tion of  mercury  with  the  iodides. 

Gummatous  tumors  may  form  in  any  muscle  commencing  in  the  peri- 


SYPHILIS   OF   THE   BURS^E.  293 

mysium.  A  gumma  here,  as  elsewhere,  consists  of  a  round-celled 
infiltration,  which  finally  becomes  absorbed,  or  undergoes  coagulation 
necrosis,  softens,  and  finds  its  way  to  the  surface,  acting  just  as  gumma 
does  in  the  subcutaneous  connective  tissue. 

The  symptoms  are  at  first  only  a  tumor  in  the  muscle,  which  is  pain- 
less, and  often  of  considerable  size  when  first  discovered.  In  a  large 
muscle  the  tumor  is  found  to  be  stationary,  when  the  muscle  is  thrown 
into  contraction ;  at  other  times  movable.  The  skin  is  normal  over  the 
tumor  until  the  latter  approaches  the  surface,  where  it  begins  to  soften, 
and  some  pain  is  complained  of,  especially  at  night. 

The  termination  of  gumma  leads  to  the  destruction  of  all  the  muscular 
fibres  involved,  which  are  replaced  by  the  formation  of  new  connective 
tissue.  Prompt  treatment  alone  can  arrest  destruction  of  tissue. 

The  diagnosis  is  possible,  in  many  instances,  only  by  aid  of  the  his- 
tory and  concomitant  symptoms,  and  by  the  effect  of  treatment. 

Treatment  with  iodides  in  large  doses  is  generally  promptly  effective 
in  the  earlier  stages  of  gumma.  After  the  mass  has  softened,  it  is  some- 
times incapable  of  preventing  perforation  and  discharge. 

SYPHILIS  OF  TENDONS  AND  APONEUKOSES. 

The  sheaths  of  the  tendons  may  become  the  seat  of  effusion  in  second- 
ary syphilis,  swelling  up  in  triangular  form,  with  the  base  toward  the 
fingers,  or  the  effusion  may  be  less  generalized.  The  swelling  fluctuates, 
and  usually  is  unattended  by  pain.  Occasionally,  however,  pain,  heat, 
redness,  and  interference  with  function  are  as  great  as  in  inflammatory 
tenosynovitis. 

The  tendons  about  any  of  the  joints  may  be  involved  in  this  process, 
but  the  affection  is  rare,  and  the  back  of  the  wrist  the  most  common  seat. 

The  tendons  and  aponeuroses  are  sometimes  involved  in  localized  or 
diffuse  interstitial  connective-tissue  thickening,  and  extensive  gummata 
of  nearly  all  the  large  tendons  have  been  placed  on  record.  Gummata 
of  tendons  are  painless  until  they  create  irritation  by  their  size  or  by 
commencing  to  soften.  When  they  become  painful,  the  muscle  from 
which  they  spring  generally  refuses  to  act. 

Treatment  is  that  of  the  stage  of  the  disease  to  which  the  lesions  be- 
long :  mercury  internally  for  the  early  localized  type ;  mixed  treatment 
for  the  diffused  form ;  iodides  alone  for  gummata. 

SYPHILIS  OF  THE  BURS.E. 

The  bursse  may  be  attacked  in  both  the  secondary  and  tertiary  stages 
of  the  disease,  either  as  an  acute  bursitis  with  effusion,  which  is  rare, 
more  commonly  by  gummatous  infiltration.  The  bursa  in  front  of  the 


294  VENEREAL  DISEASES. 

patella  is  the  most  frequently  involved.  The  bursa  on  the  side  of  the  knee 
and  that  behind  the  olecranon  have  been  similarly  affected.  The  ear- 
lier form  of  this  malady  appears  much  like  a  bursitis  from  other  causes. 
Its  diagnosis  is  easy  when  other  phenomena  of  syphilis  coexist,  and  on 
account  of  the  fact  that  it  yields  to  specific  treatment. 

The  gummatous  form  may  remain  indolent  for  an  extended  period, 
or,  the  surrounding  tissues  having  become  infiltrated  and  the  overlying 
skin  adherent,  the  tumor  may  discharge  externally,  leaving  a  superficial 
ulcer  and  a  sinus  leading  down  to  the  infiltrated  bursal  sac,  which  may 
persist  for  a  long  period.  The  course  of  tertiary  syphilitic  bursitis  iz 
very  protracted.  Concomitant  symptoms,  study  of  the  case,  and  its  his- 
tory must  be  relied  upon  to  clear  up  the  diagnosis. 

Treatment  should  be  mixed.  The  effect  is  much  less  rapid  in  the  late 
than  in  early  manifestation.  The  iodides  are  more  powerful  in  dispers- 
ing the  tumor  than  mercurials,  but  the  combination  of  mercury  with  the 
large  doses  of  the  iodides  seems  to  increase  the  effect  of  the  latter. 

SYPHILIS  OF  THE  JOINTS. 

The  joints  are  involved,  both  in  secondary  and  in  tertiary  syphilis. 
The  joint  affection  in  the  former  case  is  attended  by  pain,  spontaneous 
and  on  pressure,  and  by  fever,  which  may  run  to  such  a  height  as  to 
make  the  malady  assume  the  form  of  acute  articular  rheumatism.  There 
is  generally  some  effusion  of  fluid.  The  affection  always  gets  well  and 
yields  to  mercury. 

The  acute  form  may  also  occur,  late  in  syphilis. 

A  chronic  hydarthrosis,  due  to  tertiary  syphilis,  without  any  thicken- 
ing of  the  structures  forming  the  joint,  is  occasionally  encountered. 

Gummatous  infiltration  of  the  small  joints,  terminating  in  their  dis- 
integration and  destruction,  sometimes  with  opening  and  discharge  ex- 
ternally, comes  under  the  heading  of  dactylitis. 

The  larger  joints  also  suffer  in  tertiary  syphilis,  their  ligaments,  cap- 
sule, and  the  surrounding  tissues  becoming  the  seat  of  gummatous  in- 
filtration. 

The  gummy  deposit  takes  place  in  the  capsule  in  a  diffused  form, 
with  localized  areas  of  greater  thickening.  Together  with  this  thicken- 
ing of  the  capsule,  there  occurs  slowly  an  inconsiderable  effusion  into  the 
joint.  There  is  no  pain  early  in  the  disease  and  no  fever. 

The  malady  is  usually  unilateral.  As  the  changes  progress  nocturnal 
pains  often  set  in,  and  when  in  the  knee  the  joint  assumes  more  or  less 
of  a  fusiform  shape,  recalling  white  swelling,  with  which  it  is  ordinarily 
confounded. 

Finally  the  cartilages  soften  and  disintegrate,  gummatous  material 
fills  the  cavity  of  the  joint.  Softening  of  the  gumma  takes  place  and 


SYPHILIS   OF   THE   JOINTS.  295 

discharges  externally,  or  even,  in  the  case  of  absorption,  the  joint  may  be- 
come disorganized,  its  functions  forfeited,  and  ankylosis  ensues. 

The  diagnosis  of  this  affection  is  with  white  swelling.  Ordinarily  the 
diagnosis  is  made  by  the  history  and  the  effect  of  treatment. 

Treatment. — Mixed  treatment,  with  the  iodides  in  excess,  yields 
striking  results  in  this  malady.  The  employment  of  massage  and  pressure, 
together  with  local  use  of  mercurial  plasters  and  of  the  oleate,  assists  in 
the  rapidity  of  the  cure. 

Dactylitis. — This  is  an  important  form  of  syphilis  which  involves  the 
fingers  and  toes.  It  occurs  in  two  forms :  the  one  involving  the  joint  and 


FIG.  99.— Dactylitis  of  the  Toe,  diffuse  form.    (After  Taylor.) 

more  superficial  tissues,  the  other  the  bone  and  joint.  Both  are  gumma- 
tous. 

The  first  form  is  a  diffuse  gummy  infiltration  of  the  periosteum  and 
subcutaneous  tissues.  But  one  phalanx  (generally  the  proximal)  may  be 
involved,  or  the  whole  digit  may  share  in  the  morbid  process  (Fig.  99). 

The  swelling  in  this  form  of  dactylitis  is  firm,  ends  abruptly,  and 
does  not  shade  off  into  the  surrounding  skin.  It  is  not  attended  by 
pain  except  on  motion,  and  the  latter  is  generally  interfered  with  by  the 
swelling.  The  color  of  the  integument  is  often  a  livid,  light  red,  whether 
there  is  any  eruption  upon  the  skin  or  not.  If  the  disease  is  allowed  to 
progress,  the  ligaments  of  the  joints  next  become  involved.  Effusion 
into  the  joint  is  exceptional  in  this  form  of  disease.  Finally,  the  carti- 
lages erode  and  the  joint  is  destroyed,  the  bones  becoming  implicated  at 
this  time. 

The  course  of  the  affection  is  slow,  and  relapse  not  uncommon.  Per- 
sistent treatment  is  always  curative,  but,  if  the  cartilages  have  been  in- 
volved or  the  joint  disintegrated,  loss  of  function  necessarily  follows. 

The  other  form  of  dactylitis  is  a  gummy  tumor  of  the  bone.  One  or 
more  phalanges  may  be  attacked.  The  common  seat  of  the  tumor  in  a 
typical  case  is  the  proximal  phalanx  (Fig.  100).  Effusion  may  take  place 


296 


VENEREAL   DISEASES. 


into  a  joint,  and  the  latter  may  be  involved  in  the  disease  even  to  a  greater 
extent  than  the  intervening  phalanx. 

The  superficial  and  surrounding  tissues  often  escape  implication  in  an 
extraordinary  way.     The  skin  may  be  of  a  livid  pink  from  tension,  but 


FIG.  100.— Dactylitis  of  the  Proximal  Phalanx.    (After  Berg.) 

not  at  all  structurally  altered ;  the  nail  generally  escapes,  even  when  the 
ungual  phalanx  is  the  seat  of  the  disease. 

The  natural  evolution  of  this  malady  seems  to  be  that  it  culminates 
after  a  time,  and  the  gummy  tissue,  not  being  organized,  is  reabsorbed 
without  breaking  down.  Very  rarely  does  the  gummy  tissue  disintegrate 
and  ulcerate  its  way  to  the  surface.  As  a  result  of  this  interstitial  ab- 
sorption, the  bone  atrophies  visibly  and  the  phalanx  shortens.  When 
two  bones  and  an  intervening  joint  have  been  involved,  the  shortening 


FIG.  IOL 


due  to  absorption  is  so  coniderable  as  to  reduce  the  whole  finger  greatly 
in  length.  The  accompanying  cut  (Fig.  101)  illustrates  this  condition  and 
represents  a  case  of  McCready's,  pictured  also  by  Taylor.  The  deformity 
produced  was  very  striking.  There  had  been  no  ulceration  reaching  the 


SYPHILIS  OF  THE  BONES.  297 

surface  in  this  case,  and  the  functions  of  the  fingers  were  comparatively 
good. 

When  the  centre  of  a  phalanx  only  is  involved  in  the  disease,  absorp- 
tion of  the  gummy  material  may  leave  the  bone  separated  in  its  centre. 
In  such  a  case  the  two  ends  generally  come  together  as  a  false  joint,  and 
the  skin  over  them  contracts,  so  as  to  conform  itself  to  the  new  order  of 
things.  There  is  no  pain  at  all,  as  a  rule,  in  this  form  of  dactylitis. 

The  diagnosis  in  dactylitis  is  very  easy.  The  diffuse  variety  can 
hardly  be  mistaken  for  any  other  malady.  Gout  and  all  ordinary  in- 
flammations are  too  painful  to  be  confounded  with  it.  The  second  form 
might  be  mistaken  for  enchondroma,  which  also  is  painless,  and  apt  to 
appear  upon  the  phalanges.  Enchondroma  grows  more  slowly,  and  is 
more  circumscribed  in  area.  A  close  study  of  the  course  of  the  affection 
will  clear  up  the  diagnosis. 

Prognosis. — Syphilitic  dactylitis,  even  if  left  to  itself,  always  gets 
well ;  but  may  do  so  at  the  expense  of  deformity  and  more  or  less  inter- 
ference with  function.  Its  progress  may  be  arrested  at  almost  any  stage 
by  bold  and  efficient  treatment. 

Treatment. — The  diffuse  form  requires  mercury  in  combination  with 
iodide  of  potassium  or  some  other  iodide,  which  (the  iodide)  must  be  un- 
sparingly pushed  as  rapidly  as  the  stomach  will  allow.  The  second  form 
generally  yields  a  very  ready  response  to  the  vigorous  use  of  the  iodides. 
The  complete  success  of  treatment  in  any  case  is  slow. 

SYPHILIS  OF  THE  BONES. 

The  bones  may  be  involved  in  secondary,  as  well  as  in  late  syphilis, 
the  lesion  being  osteoperiostitis,  osteitis,  or  osteomyelitis — rarefying  or 
gummatous.  The  epiphyseal  changes  in  the  long  bones  will  be  noticed 
under  the  head  of  inherited  syphilis.  Subperiosteal  nodes  are  found  in 
secondary  syphilis  upon  a  number  of  different  bones.  These  nodes,  how- 
•ever,  are  not  the  destructive  gummata  of  late  syphilis;  indeed,  rather 
rarely  do  they  go  on  to  the  formation  of  exostoses,  the  common  termina- 
tion of  ordinary  nodes  in  tertiary  disease.  The  secondary  syphilitic  node 
is  often  only  a  subperiosteal  hypersemia  and  infiltration,  coming  on 
suddenly,  perhaps  'as  the  result  of  local  injury,  disappearing  promptly 
under  treatment,  and  leaving  behind  no  trace  of  its  existence. 

Some  few  of  the  secondary  subperiosteal  swellings,  however,  do  lead 
to  local  thickening  of  bone,  which  remains  permanent. 

Osteocopic  pains  commonly  occur  in  secondary  syphilis,  and  often  in 
late  syphilis  as  well.  They  are  pains  of  a  splitting,  boring  character, 
coming  on  at  night  in  certain  bones,  sometimes  with  great  regularity 
ceasing  toward  morning.  These  pains  are  probably  due  to  slight  perios- 
teal  swelling,  attended  by  considerable  subperiosteal  hypersemia.  The 


298  VENEREAL  DISEASES. 

warmth  of  the  bed  seems  to  intensify  them  (Kicord).     Barely  the  pains 
come  on  by  day,  and  cease  by  night. 

They  occur  about  the  head  and  neck,  the  shoulders,  elbows,  and 
knees,  and  in  the  continuity  of  the  long  bones.  The  previous  use  of 
mercury  has  nothing  whatsoever  to  do  with  their  causation ;  on  the  con- 
trary, they  are  not  apt  to  come  at  all  if  mercury  has  been  commenced  early 
enough,  and  they  disappear  more  quickly  under  the  use  of  mercury  than 
under  the  employment  of  any  other  drug. 

In  connection  with  the  pains,  sometimes  when  the  bone  is  superficial 
(cranium,  tibia),  the  periosteum  is  apparently  raised  a  little,  and  gives 
to  the  fingers  an  obscure  sense  of  oedema. 

The  night  headache  of  early  syphilis  is  usually  an  intense  osteocopic 
pain. 

Osteocopic  pains  early  in  syphilis  are  favorably  influenced  by  both 
mercury  and  the  iodides,  but  mercury  has  decidedly  the  more  power  over 
them.  When  the  pains  are  only  moderate,  they  do  not  call  for  any  de- 
viation from  the  general  treatment  which  the  stage  of  the  disease  calls  for 
in  which  they  occur.  When  they  are  intense,  however,  mercury  in 
minute  doses,  frequently  repeated,  will  sometimes  relieve  them  very 
promptly.  From  one-fifteenth  to  one-tenth  of  a  grain  of  calomel  may  be 
given  in  this  treatment  hourly  for  twelve  hours.  Then  it  is  well  to  ar- 
rest treatment  for  one  day,  and  repeat  a  similar  course  on  the  next.  The 
object  of  interrupting  treatment  is  the  fear  of  salivation  or  of  intestinal 
disturbance,  of  which  there  is  some  danger  when  this  method  is  pushed 
in  susceptible  cases. 

When  osteocopic  pains  come  on  in  late  syphilis,  they  generally  indi- 
cate a  tendency  to  serious  disease  of  bone,  and  call  for  the  iodides  in  large 
doses.  The  mercurials  are  also  of  advantage  here,  but  the  iodides  out- 
rank them. 

Osteoperiostitis. — The  syphilitic  node  is  an  inflammatory  osteoperi- 
ostitis,  terminating  generally  in  new  formation  of  bone.  The  lump  thus 
formed  is  raised  over  a  variable  area  in  rounded  form,  which  gradually* 
shades  off  into  the  surrounding  tissues.  This  lump  is  soft,  and  at  first 
quite  painful,  especially  upon  pressure.  Manipulation  proves  it  to  be 
attached  to  the  bone.  The  skin  over  it  is  freely  movable,  and  not  dis- 
colored. There  is  often  oedema,  especially  in  young  nodes  of  large  size. 
The  pain  in  these  nodes  is  sometimes  considerable,  especially  if  they  are 
situated  on  the  shin,  and  if  the  patient  walks  or  stands  much.  The  pain 
is  quite  certain  to  be  intensified  at  night. 

The  bones  most  often  involved  are  the  flat  bones  (cranium)  and  super- 
ficial bones  (tibia,  clavicle,  ulna).  Local  injury,  a  blow,  will  sometimes 
cause  a  node  to  appear,  but  neither  situation  nor  local  violence  is  neces- 
sary for  their  production,  for  they  sometimes  grow  from  the  inner  table 
of  the  skull,  where  they  cause  great  damage  by  pressure,  and  they  are 


SYPHILIS   OF  THE  BONES.  299 

occasionally  found  upon  a  deep-seated  bone  (femur,  vertebral  column) 
well  down  among  the  muscles. 

The  date  of  appearance  of  nodes  is  late  in  syphilis.  Early  forms 
do  occur,  as  already  mentioned;  but  they  are  not  important,  and  gener- 
ally disperse,  leaving  no  trace. 

Their  course  is  generally  slow.  After  remaining  soft  for  a  vary- 
ing period,  they  become  firmer,  and  gradually  disappear  by  absorption 
under  treatment.  Occasionally  a  node  softens  centrally,  the  skin  over 
it  becomes  involved,  red,  adherent.  The  softened  node  discharges  and 
a  syphilitic  ulcer  remains,  the  floor  of  which  is  bone  denuded  of  its  peri- 
osteum. This  bone  becomes  black  or  brown  where  it  is  exposed,  and 
often  a  superficial  flake  necroses,  separates  in  due  time,  and  comes  away, 
after  which  the  ulcer  heals.  On  the  skull  the  outer  table  comes  away 
generally,  the  inner  table  remaining,  perhaps  perforated  by  a  number  of 
holes  through  which  the  dura  mater  may  be  seen  and  felt. 

Sometimes  a  node  will  remain  as  a  hard,  fibrous  lump,  perfectly  pain- 
less and  as  solid  as  wood  for  a  number  of  years,  causing  no  inconveni- 
ence. Such  a  node,  after  existing  for  years,  may  suddenly  soften  and 
melt  away,  involving  the  bone  in  destruction,  large  portions  of  the  super- 
ficies of  which  necrose  in  the  floor  of  the  ulcer  which  after  healing  leaves' 
a  white,  puckered,  adherent  cicatrix,  often  pigmented  at  the  circumference. 

Exostoses. — Finally  and  most  commonly,  a  node,  having  existed  some 
time,  undergoes  partial  transformation  into  true  bone  (formative  osteitis). 
Such  new  formations  of  bone  cannot  be  removed  by  treatment.  They 
remain  permanent ;  but  after  a  time  lose  their  sensitiveness  and  constitute 
simple  exostoses.  These  exostoses  on  the  inside  of  the  skull  may  occasion 
dangerous  symptoms,  such  as  paralysis  and  convulsions. 

The  form  of  bony  outgrowth  due  to  syphilis,  which  is  at  first  more  or 
less  movable  and  later  becomes  attached,  has  been  called  epiphysary  exos- 
tosis^  It  is  an  irregularly  shaped  ridge  or  prominent  pedunculated  bony 
•formation  occurring  about  the  epiphysary  ends  of  long  bones,  recalling  the 
outgrowths  seen  in  rheumatic  gout. 

Besides  periostitis  there  may  be  a  general  rarefying  osteitis  (usually  of 
a  long  bone)  involving  a  portion  or  the  whole  of  a  bone  in  a  painful  gen- 
eral thickening  due  to  round-cell  proliferation  in  the  subperiosteal  tissue, 
and  cellular  infiltration  within  the  osseous  canals. 

The  diagnosis  is  not  difficult.  The  course  of  the  growth,  and  particu- 
larly the  nocturnal  pains,  suggest  a  search  for  a  syphilitic  history,  and 
put  the  physician  on  the  right  track  to  discover  the  nature  of  the  affection. 

The  treatment  of  osteoperiostitis  and  rarefying  osteitis  is  that  of  late 
syphilis. 

Gumma  of  Bone. — A  gummy  tumor  late  in  syphilis  may  form  any- 
where in  a  bone — under  the  periosteum  (gummatous  osteoperiostitis)  or  in 
the  medullary  tissue  (gummatous  osteomyelitis). 


300  VENEREAL   DISEASES. 

The  subperiosteal  gumma  is  found  chiefly  upon  the  clavicle,  skull, 
sternum,  ribs,  tibia,  ulna.  It  commences  like  a  node  and  tends  always 
to  soften,  while  the  less  active  node  tends  naturally  to  remain  organized. 
The  gumma  is  an  acute  process,  like  the  osteitis  and  periostitis  already 
described,  but  much  more  active.  Consequently,  it  is  more  serious,  more 
destructive. 

The  gumma,  commencing  like  a  node  and  advancing  rapidly,  softens, 
attaches  itself  to  the  skin  and  discharges,  its  puriform  debris  remaining 
as  an  ulcer  with  dead  bone  at  the  bottom.  Instead  of  discharging,  gumma 
of  bone  may  remain  a  soft  mass  for  a  long  time  and  undergo  caseous 
degeneration. 

Gumma  of  the  medullary  membrane  in  the  long  bones  is  uncommon. 
The  whole  bone  swells,  and  finally  gives  way.  Ultimate  atrophy  of  the 
portion  of  bone  involved  is  to  be  expected. 

Medullary  gumma  of  the  short  bones  is  not  very  uncommon.  A  type 
of  such  formations  already  described  is  seen  in  dactylitis. 

The  diffuse  thickening  of  bone,  referred  to  in  connection  with  syphi- 
litic osteoperiostitis,  is  often  a  gummatous  process,  the  connective  tissue 
around  the  vessels  permeating  the  bone,  in  the  Haversian  canals  and 
canalicules,  being  the  matrix  in  which  gelatinous,  gummatous  hyperplasia 
occurs,  afterward  drying  up  and  being  absorbed,  leaving  the  enlarged 
bone  very  porous,  or  remaining  degenerated  in  the  form  of  cheesy  deposits. 

In  the  flat  bones,  and  particularly  in  the  diploe  of  the  skull-cap, 
syphilitic  gumma  takes  the  form  of  an  infiltration,  widening  the  bony 
lacunae,  cutting  off  the  vitality  of  the  thin  plates  of  bone  involved,  and, 
by  its  gradual  increase,  separating  the  two  plates  of  condensed  bone  from 
each  other.  Finally,  a  piece  of  condensed  bone  may  die  and  gradually 
exfoliate.  The  external  table  of  the  skull  over  a  considerable  area  may 
perish  in  this  way  (Fig.  102).  Eburnation,  condensation,  and  thickening  of 
bone  take  place  here  as  elsewhere  with  more  or  less  tendency  to  osteophytic 
and  hyperosteal  formations.  Sometimes  the  inner  table  of  the  skull 
necroses  in  connection  with  diffuse  gumma  of  the  diploe,  leading  to  changes 
in  the  dura  mater  and  brain,  and  to  the  most  serious  nervous  symptoms. 

When  the  very  thin  bones  are  attacked  by  gummatous  changes  they 
ulcerate  and  in  part  necrose,  portions  of  dead  bone  coming  away  entire. 
This  is  the  rule  in  the  case  of  the  thin  bones  of  the  nose,  palate,  etc. 
The  bones  of  the  nose  are  peculiarly  liable  to  destruction  from  syphilitic 
processes. 

As  secondary  results  of  the  changes  in  bone  produced  by  syphilis,  be- 
sides necrosis,  caries,  and  hyperostosis,  may  be  mentioned  a  fragility  of  the 
porous  bone,  rendering  its  fracture  very  easy  and  its  repair  slow  and 
imperfect.  Damage  may  be  caused  through  pressure,  by  hyperostoses, 
upon  soft  parts,  cranial  nerves,  spinal  nerves,  and  the  eye  in  orbital 
exostosis. 


SYPHILIS  OF   THE   BONES.  301 

Finally,  it  is  necessary  to  emphasize  the  fact  that  mercury  has  noth- 
ing to  do  with  disease  of  the  bone. 

Mercury  given  in  excess  to  the  point  of  salivation  may,  and  certainly 
does,  threaten  the  maxillary  bones,  especially  the  alveolar  process,  with 
destruction ;  but  aside  from  this,  mercury  does  not  cause  any  symptoms 
which  might  be,  and  usually  are,  produced  by  the  poison  of  syphilis. 

Treatment. — As  a  rule,  all  forms  of  bone  disease,  from  the  painful 
spot  to  the  gumma,  respond  to  the  iodides.  The  treatment  is  that  of 


FKJ.  103. 

late  syphilis.      Mercury  is  beneficial  in  the  osteocopic  pains  and  all 
lesions  occurring  early  in  the  disease. 

SYPHILIS  OF  CARTILAGE. 

When  a  joint  is  involved,  or  syphilis  attacks  the  expanded  end  of  a 
bone  capped  by  cartilage,  the  latter  naturally  softens,  becomes  eroded, 
and  is  destroyed  by  the  neighboring  disease.  The  fibro-cartilage  of  the 
ear  is  often  invaded  by  an  ulcerative,  tubercular  syphilide  starting  in  the 
superficial  tissues.  The  laryngeal  and  tracheal  cartilages  are  a  very 
common  seat  of  syphilitic  perichondritis,  occasionally  gummatous  de- 
posits involve  their  vitality,  and  portions  of  the  cartilage  may  fall  into 
necrosis,  just  as  a  bone  does  under  similar  circumstances.  Gummata 
upon  the  costal  cartilages  act  like  the  same  lesions  on  bone.  The  inter- 
vertebral  fibro-cartilages  are  sometimes  involved  in  gummatous  processes, 
but  rarely  so. 


CHAPTER  XIII. 

SYPHILIS   OF  THE   VISCERA. 

THE  RESPIRATORY  SYSTEM. 

IN  the  nose,  in  early  syphilis,  ery thematous  lesions  and  mucous  patches 
are  apt  to  occur.  Their  symptoms  are  those  of  catarrh.  Young  people 
suffer  more  than  adults  from  nasal  symptoms,  and  babies  with  inherited 
disease  most  of  all.  The  mucous  patch  and  the  erythematous  lesions 
have  the  same  physical  characteristics  here  as  they  have  in  the  throat. 

In  tertiary  syphilis,  gummatous  ulcers  upon  the  mucous  membranes 
of  the  nose  involve  its  cartilages  below  and  its  thin  bones  above  in  de- 
struction; and  gummy  tumors  are  quite  certain  to  destroy  the  bridge 
and  other  portions  of  the  bones  of  the  nose  unless  arrested  by  treatment. 
After  cure,  the  bridge  of  the  nose  is  permanently  sunken  and  its  point 
turned  up,  giving  a  physiognomy  which  is  almost  pathognomonic  of  late 
syphilis. 

While  the  destructive  process  involving  the  bone  is  going  on  within 
the  nose,  the  patient  has  "  syphilitic  ozaeua, "  or,  catarrh,  which  is  more 
or  less  purulent  in  character.  The  odor  of  the  breath  in  these  cases  is 
peculiarly  offensive.  The  inside  of  the  nose  contains  yellow  and  black 
dry  scabs  closely  adhering  to  ragged  ulcers,  or  to  perforations  through 
the  septum  or  elsewhere.  Pieces  of  dead  bone  are  frequently  discharged 
through  the  nostrils,  or  remain  as  sequestra  and  keep  up  the  local  irri- 
tation. The  nasal  duct  often  gets  shut  up,  leading  to  abscess  of  the 
lachrymal  sac,  conjunctivitis,  necrosis  of  the  lachrymal  bone.  The 
Eustachian  tube  may  be  closed,  and  inflammatory  trouble  in  the  middle 
ear  be  set  up,  leading  to  deafness. 

If  the  disease  is  situated  high  up  in  the  nasal  cavity,  the  olfactory 
sense  may  be  destroyed  or  temporarily  impaired. 

The  diagnosis  of  the  lesions  above  described  rests  upon  their  course, 
clinical  characters,  and  syphilitic  history. 

The  treatment  of  lesions  of  the  nasal  cavity  is  that  of  the  stage  in 
which  they  occur.  Local  treatment  for  the  early  erythematous  lesions 
should  be  stimulating.  In  the  late  stages  the  nasal  cavity  should  be 
cleansed  with  an  antiseptic  spray  and  loose  pieces  of  dead  bone  should  if 
possible  be  removed. 

The  Larynx. — The  mucous  membrane  of  the  larynx  suffers  from  ery- 


SYPHILIS   OF   THE  VISCERA.  303 

thernatous  and  mucous  patches  in  early  syphilis.  These  lesions  are  the 
same  here  as  elsewhere  on  the  mucous  membranes  (see  page  284).  They 
are  the  better  for  local  treatment,  but  get  well  without  it.  Mercurial 
inhalations  sometimes  hasten  their  disappearance. 

In  the  tertiary  stage  chronic  inflammation  attacks  the  cartilages  of 
the  larynx,  and  deep  ulcerations  appear  upon  the  mucous  membrane,  the 
vocal  cords,  and  in  the  muscles  of  the  larynx. 

Non-ulcer  ative  laryngitis  due  to  syphilis  is  a  chronic,  constructive, 
connective-tissue  hyperplasia,  involving  the  cords  as  well  as  all  the  tissues 
within  the  larynx.  The  newly  formed  material  contracts  here  as  else- 
where, binds  and  draws  together  the  tissues  within  the  larynx,  stiffens 
the  vocal  cords  into  unyielding  rigidity  in  the  closed  state,  and,  finally, 
may  obstruct  respiration  entirely,  no  previous  ulceration  having  occurred. 
The  cartilages  do  not  become  necrotic  in  this  affection,  and  there  is  no 
loss  of  tissue,  except  of  muscular  tissue  by  atrophy  from  pressure. 

The  symptoms  of  this  affection  are  a  hoarseness,  lasting  for  months, 
even  years,  slight  pain  on  pressure,  gradually  increasing  dyspncea,  the 
voice  finally  being  reduced  to  a  whisper,  the  patient  becoming  enfeebled, 
cyanotic,  and  emaciated.  The  larynx  is  stenosed,  the  mucous  membrane 
livid,  the  intralaryngeal  tissues  are  thickened.  Eapid  oedema  of  the 
glottis  is  liable  to  come  on  at  any  time. 

The  diagnosis  should  be  made  by  direct  examination  with  the  laryn- 
goscope. In  tuberculous  laryngitis  there  is  generally  consolidation  at  the 
apex  of  the  lung,  and  with  the  laryngoscope  surface  ulceration  in  the 
larynx  may  be  detected,  if  present.  Papilloma  of  the  vocal  cords  which 
may  give  all  the  symptoms  of  syphilitic  laryngitis  is  distinguished  in  the 
same  manner. 

Treatment  is  mixed — mercury  with  the  iodides.  It  must  be  long  con- 
tinued. If  commenced  early,  it  is  promptly  curative ;  later,  it  is  slower 
in  its  action  and  less  effective.  In  the  stage  of  stenosis,  tracheotomy  is 
sometimes  necessary  to  relieve  impending  suffocation. 

Ulcerative  laryngitis  may  accompany  the  affection  last  described,  or 
occur  independently  of  it. 

The  ulcers  are  like  tertiary,  gummy  ulcers  of  the  pharynx,  and  may 
occur  anywhere  within  the  larynx,  on  the  cords,  behind  the  epiglottis, 
running  down  in  connection  with  ulcers  in  the  throat,  or  occurring  inde- 
pendently. 

The  ulcers  may  start  as  in  the  pharynx,  upon  the  surface  and  eat  in, 
or  a  gumma  may  form  beneath  the  perichondrium  of  a  laryngeal  cartilage 
and  eat  outward,  in  either  case,  especially  the  latter,  a  portion  of  the 
cartilage  is  liable  to  be  involved  in  necrotic  changes  and  to  exfoliate.  A 
gumma  of  the  larynx  may  work  its  way  out  externally,  giving  rise  to 
fistula. 

The  ulcers,  surrounded  by  considerable  oedema,  are  visible  with  the 


304  VENEREAL   DISEASES. 

laryngoscope.  The  final  cicatrization  after  cure  in  these  cases  may  lead 
to  the  most  extensive  distortion  of  the  laryngeal  cavity,  or  even  to  its 
obliteration. 

The  symptoms  are  those  of  chronic  laryngitis  intensified.  Pain  is 
common,  with  expectoration  of  pus,  mixed  perhaps  with  blood  and  por- 
tions of  sloughy  tissue. 

Diagnosis. — The  symptoms  easily  localize  the  disease,  and  the  diag- 
nosis lies  between  ulcerative  tuberculour  laryngitis  and  destructive  can- 
cerous laryngitis.  In  the  former  affection  the  lungs  will  almost  always  be 
found  to  be  in  an  advanced  state  of  tuberculour  disease,  and  in  the  latter, 
the  non-ulcerated  masses  of  new  growth  can  often  be  seen  with  the  aid  of 
a  laryngoscope  and  the  diagnosis  confirmed  by  microscopic  examination. 

Treatment. — Iodide  of  potassium  should  be  given  in  large  doses,  and 
run  up  as  rapidly  as  the  stomach  will  stand.  Tracheotomy  may  be  called 
for  on  account  of  impending  suffocation  from  oedema.  Cicatricial  changes 
are  not  favorably  affected  by  treatment,  and  may  be  so  seriously  obstruc- 
tive to  respiration  as  to  demand  tracheotomy  and  a  permanent  tube. 

The  Trachea,  Bronchi,  and  Lungs. — The  trachea  and  larger  bronchial 
tubes  are  subject  to  the  same  morbid  conditions  as  the  larynx,  but  less 
commonly  so.  The  lesion  found  in  syphilis  of  these  regions  consists  of 
dense  inflammatory  connective-tissue  hyperplasia,  accompanied  by  ulcera- 
tive changes  and  more  or  less  resultant  narrowing  (stenosis)  of  the  tubal 
lumen.  It  is  possible  for  ulcers  on  the  surface  to  eat  through  into  sur- 
rounding structures,  but  such  accidents  are  exceptionally  uncommon. 

The  symptoms  consist  of  more  or  less  dyspnoea,  localized  pain,  and 
varying  lung  symptoms,  such  as  cough,  rales,  expectoration  of  mucus  or 
blood,  etc.  If  the  lesion  be  tracheal  the  voice  is  more  likely  to  be  im- 
paired. 

The  diagnosis  is  with  tuberculous  troubles,  and  rests  mainly  upon  the 
history  and  concomitant  symptoms,  and  the  examination  for  tubercle 
bacilli. 

The  treatment  is  like  that  for  similar  conditions  in  the  larynx. 

The  Lungs, — The  lungs  are  affected  by  syphilis  in  two  ways :  in  the 
form  of  diffuse  connective-tissue  hyperplasia,  leading  to  consolidation  by 
interstitial  changes ;  and  in  the  form  of  gummy  tumor. 

Syphilitic  pulmonary  fibrosis  is  very  common  in  inherited  disease. 
It  is  often  generalized  in  both  lungs  in  the  infant.  In  the  adult  it  is 
more  commonly  circumscribed.  The  change  in  either  case  is  an  inter- 
stitial thickening  of  the  connective  tissue  between  the  air  cells,  which 
may  go  on  to  a  total  obliteration  of  the  latter  in  the  fibroid  transforma- 
tion of  the  new  cells,  and  sclerotic  shrinkage  of  the  morbid  tissue. 

The  portions  of  lung  involved  in  the  disease  are  stiff,  non-crepitant 
upon  pressure,  solid,  depressed  below  the  level  of  the  surrounding  lung. 
They  cut  like  fibrous  tissue ;  the  section  is  seen  to  be  interspersed  with 


SYPHILIS   OF  THE  VISCERA.  305 

yellow  points  of  fatty  degeneration,  and  the  bronchial  tubes,  variously 
dilated  and  contracted,  with  thickened  walls.  The  pleura  over  these 
spots  is  apt  to  be  involved  in  the  thickening. 

The  symptoms  of  pulmonary  fibrosis  are  not  pathognomonic.  They 
are  identical  with  those  of  chronic  phthisis.  Any  portion  of  the  lung, 
apex  or  base,  may  be  involved,  and  there  are  usually  the  accompaniments 
of  fever,  short  breath,  cough,  expectoration,  emaciation,  etc. 

Gummata  in  the  lungs  may  coincide  with  fibrosis,  or  come  on  inde- 
pendently. They  necessarily  go  on  to  destruction  of  the  tissues  they 
implicate. 

There  are  no  fixed  symptoms.  The  tumor  is  solid  at  first,  and  may 
be  made  out  by  percussion,  if  it  is  large  enough.  It  may  suppurate,  and 
discharging  into  a  bronchus,  leave  a  cavity  which  may  be  revealed  by 
physical  signs.  There  is  no  pain,  and  the  subjective  symptoms  are  not 
at  all  distinctive. 

The  diagnosis  of  lung  syphilis  always  rests  mainly  on  the  history,  the 
result  of  treatment,  and  the  examination  for  tubercle  bacilli  and  is  con- 
sequently for  the  most  part  tentatively  experimental. 

Treatment  may  be  rapidly  effective  of  relief — a  permanent  cure  is 
possible.  It  should  be  mixed,  with  large  doses  of  iodide  and  continued 
for  a  long  period. 

THE  DIGESTIVE  TRACT. 

The  secondary  and  tertiary  lesions  of  the  buccal  cavity  and  pharynx 
have  been  described  already. 

Sclerosis  and  Gumma  of  the  Tongue, — Sclerosis  of  the  tongue  occurs  in 
two  forms.  One  superficial,  in  which  the  mucous  and  submucous  tissues 
are  involved  in  a  general  or  circumscribed  thickening  resembling  cicatri- 
cial  tissue,  which  may  or  may  not  be  accompanied  by  ulcerations.  The 
deeper  form  of  sclerosis,  which  is  an  extension  of  the  superficial  lesion, 
results  in  local  or  general  thickening  of  the  tongue,  the  size  of  which  may 
be  very  great.  A  lobulated  condition  is  produced  which  is  quite  charac- 
teristic. The  lobules  are  separated  by  fissures  of  which  the  central  fissure 
is  the  most  pronounced,  as  this  process  is  deep  and  extensive  the  body  of 
the  tongue  is  felt  to  be  indurated  as  well  as  enlarged.  The  mucous  sur- 
face is  changed  in  color,  being  either  red,  pale  or  dirty  white.  It  is 
generally  smooth.  Ulcerations  may  be  present  as  a  result  of  irritation 
or  abrasion  caused  by  the  teeth.  Cases  are  also  reported  of  partial  and 
localized  atrophy  of  the  tongue  due  to  syphilis. 

Gummatous  lesions  of  the  tongue  are  especially  important  and  worthy 
of  study,  because  they  frequently  come  on  after  all  evidences  of  syphilis 
have  disappeared,  and  are  suggestive  of  epithelioma. 

A  gumma  may  commence  in  any  portion  of  the  tongue  except  its 
under  surface,  and  may  be  encountered  at  any  time  of  life.  Not  very 
20 


306 


VENEREAL   DISEASES. 


infrequently  it  is  bilateral,  or  there  may  be  multiple  foci  of  guminatous 
deposit.  The  gumma  commences  without  any  pain,  as  a  lump  deep 
among  the  muscles  of  the  tongue  or  under  the  mucous  membrane  j  never 
superficially  at  first,  like  an  epithelioma.  The  lump  grows,  the  mucous 
membrane  over  it  becomes  stretched  and  livid,  finally  the  tumor  softens 
centrally,  ulcerates  its  way  through  the  mucous  membrane,  and  remains 
open  as  a  gummatous  ulcer,  with  a  deep,  sloughy  cavity,  hard  base, 
fissured,  ragged,  thick,  abrupt  borders,  often  undermined  at  first,  but 
always  bound  down  and  adherent  later  on.  The  ulcer  progresses  slowly. 
The  course  of  the  affection  in  any  case  is  much  protracted,  but  the  ten- 
dency is  to  ultimate  self -limitation,  even  without  treatment,  if  the  general 
health  be  good;  and  to  cicatrization,  with  more  or  less  loss  of  tissue, 
according  to  the  extent  and  duration  of  the  ulcer. 

The  discharge  is  slight,  even  when  the  ulcer  is  at  its  height;  but 
there  may  be  phagedsena.  Pain  is  absent  or  inconsiderable,  and  the 
functions  of  the  tongue  are  not  much  disturbed.  The  lymphatic  glands 
escape  implication,  or  are  involved  only  in  an  inflammatory  way.  The 
general  health  may  be  very  little  disturbed,  or  there  may  be  marked 
cachexia. 

The  differential  diagnosis  is  with  epithelioma  of  the  tongue,  and  with 
tuberculous  ulceration.  Tuberculous  ulcers  commence  as  white  excoria- 
tions without  antecedent  tumor.  The  excoriations  enlarge  and  deepen. 
They  advance  slowly  and  are  very  obstinate  and  hard  to  heal.  Nearly 
always  the  lungs  contain  other  evidences  of  tuberculosis. 

The  differential  diagnosis  between  epithelioma  and  gumma  of  the 
tongue  is  presented  in  the  following  diagnostic  table : 


ULCERATED     EPITHELIOMA    OF     THE 
TONGUE. 

1.  Occurs  generally  late  in  life. 

2.  Possible  cancerous  antecedents. 

3.  The  ulcer  sometimes  occupies  the 
seat  of  former  ichthyosis  of  the  tongue. 

4.  Commences  superficially  and  ulcer- 
ates. 


6.  Lesion  is  unique. 

6.  Occurs  on  any  part  of  the  tongue. 

7.  Edges  everted,  tuberculated,  irregu- 
lar,  bleeding   easily  when  touched,   or 
spontaneously. 

8.  Discharge  free,  ichorous,  putrid. 

9.  Pain  spontaneous,  shooting  toward 
ear  (Fournier). 


ULCERATED  GUMMA  OF  THE  TONGUE. 

1.  Occurs  at  any  age. 

2.  Syphilitic  history. 

3.  Nothing  of  the  sort. 

4.  Commences  deep  in  the  tissues,  feel- 
ing like  a  bullet  beneath  the  mucous 
membrane.     It  softens  centrally,  and  on 
reaching    the  surface    discloses  a  deep 
ulcer. 

5.  Sometimes  multiple  and  bilateral. 

6.  Found  only  on  the  back  and  sides 
of  the  tongue,  never  beneath. 

7.  Edges    abrupt,    uneven,   hard,    ad- 
herent, covered  with  slough,  not  tuber- 
culated, not  bleeding  easily. 

8.  Discharge  slight. 

9.  Ulcer  usually  painless. 


SYPHILIS   OF  THE   VISCERA. 


307 


tJLCEBATED    EPITHELIOMA    OF    THE 
TONGUE. 

10.  Tongue  rigid,  painful,  functionat- 
ing badly. 

11.  Microscopic    characters    those    of 
epithelioma. 

12.  Lymphatic     glands     become    in- 
volved. 

13.  Antisyphilitic     treatment    of    no 
value. 

14.  Termination :    death   by  cachexia 
and  inanition. 

15.  Liable  to  return  if  cut  out. 


ULCBKATED   GTTHHA  OP  THE   TONGUE. 

10.  Functional      troubles      generally 
light. 

11.  Microscopic  characters  those  of  a 
degenerating  gumma. 

12.  Lymphatic  glands  generally  remain 
exempt. 

13.  Antisyphilitic  treatment  generally 
promptly  beneficial. 

14.  Spontaneous  cure  without  medicine 
possible. 

16.  Does  not  return  if  cut  out  entirely. 


Treatment. — Gumma  of  the  tongue  usually  yields  a  rapid  response  to 
iodide  of  potassium  in  large  doses,  if  the  remedy  is  given  before  the  tumor 
has  softened.  After  ulceration,  the  effect  of  treatment  is  less  rapidly 
effective,  but,  nevertheless,  is  generally  quite  prompt.  In  cachectic  con- 
ditions, and  when  the  stomach  will  not  bear  the  iodides,  the  result  of 
treatment  is  slow  and  often  unsatisfactory. 

The  (Esophagus, — Gummatous  deposits  may  originate  in  the  cesopha- 
geal  walls  leading  to  ulceration  and  eventually  to  stenoses  from  cicatricial 
contraction. 

These  lesions  are  very  rare.  Their  symptoms  are  pain  on  swallowing, 
with  evidence  of  some  obstruction  in  the  canal.  When  the  ulcers  get 
well,  the  resulting  stricture  calls  for  treatment  by  dilatation,  severe  cases 
may  require  gastrostomy.  Specific  treatment  if  begun  early  enough  may 
forestall  the  formation  of  stricture,  but  will  not  cause  its  absorption  when 
once  it  has  formed. 

The  Stomach  and  Intestines. — Early  in  syphilis,  especially  during  the 
fever,  nausea,  indigestion,  and  other  functional  troubles  of  the  stomach 
are  not  uncommon. 

Thickening  and  ulceration  of  the  stomach  have  been  ascribed  to  ter- 
tiary syphilis,  but  have  not  been  clearly  defined.  Presumably  these 
lesions  occur  here  as  they  do  in  other  portions  of  the  alimentary  canal, 
but  they  are  more  likely  to  be  discovered  on  the  post-mortem  table  than 
they  are  to  be  recognized  during  lifetime. 

Gummatous  ulcers  occur  both  in  the  small  and  large  intestines.  Cases 
have  been  reported  by  various  observers  (Oser,  Meschede,  Wagner,  Black- 
more,  and  others),  the  lesions  having  been  found  after  death.  Such  ulcers 
may  be  single  or  multiple  and  result  sometimes  in  perforation,  followed 
by  fatal  peritonitis.  Continuous  diarrhoea  with  occasional  bloody  stool 
and  colicky  pains  with  the  coexistence  of  a  syphilitic  history  and  visible 
lesions  elsewhere,  would  naturally  lead  to  the  suspicion  of  the  existence 
of  such  lesions. 

The  Rectum. — In  early  syphilis  there  may  be  ulcers  upon  the  mucous 


308  VENEREAL   DISEASES. 

membrane  of  the  rectum  and  anus  which  behave  like  syphilitic  ulcers  else- 
where. They  are  generally  surrounded  by  an  unusual  amount  of  inflam- 
matory oedema. 

Condylomata  lata  appear  upon  the  integument  of  the  arms  and  around 
the  genitals.  They  are  mucous  patches  which  grow  from  the  skin  instead 
of  the  mucous  surface.  They  commence  as  small  moist  papules  and  be- 
come elevated  by  infiltration  when  they  present  the  characteristic  appear- 
ance of  flat  warty  excrescences  (Fig.  89,  page  286). 

Localized  or  diffuse  gummatous  infiltration  and  ulceration  constitute 
another  form  in  which  the  disease  appears  in  the  rectal  region.  A  stric- 
ture produced  by  this  condition  may  be  of  only  temporary  duration.  It 
may  disappear  under  treatment. 

Finally  there  occurs  a  chronic  hyperplastic  infiltration  into  the  sub- 
mucous  tissue  of  the  rectum  (ano-rectal  syphiloma  of  Fournier),  dependent 
upon  active  cellular  proliferation.  This  lesion  is  slow  in  forming.  Event- 
ually the  new  tissue  becomes  fibrous  in  character  and  contracts,  producing 
a  dense  fibroid  stricture  without  previous  ulceration.  Ulceration  may 
occur  concomitantly,  but  is  not  an  essential  part  of  the  malady.  The 
symptoms  are  those  of  proctitis  with  some  loss  of  power  in  the  sphincter, 
followed  later  by  difficulty  in  defecation,  small  stools,  and  constant  mucous 
discharge.  This  condition  when  fully  developed  is  a  permanent  one. 

Diagnosis. — When  ulceration  has  preceded  stricture  of  the  rectum,  it 
is  difficult  to  differentiate  the  chancroidal  form  from  that  occasioned  by 
ulcerated  mucous  patches. 

The  true  fibroid  stricture  is  more  easily  recognized.  No  other  malady 
produces  the  livid,  flat,  softish,  semi-elastic  external  patches  extending 
into  the  sphincter  and  weakening  its  power,  attended  by  the  denser  infil- 
tration higher  up,  with  little  or  no  surface  ulceration  and  comparatively 
little  pain. 

Treatment. — In  all  the  tertiary  syphilitic  affections  of  the  digestive 
tract  dietary  expedients  and  precautions  are  essential.  The  effect  of 
mercury  in  all  of  these  conditions  is  good  hypodermatically  or  by  inunc- 
tion; but  it  may  be  necessary  to  administer  the  drug  so  as  to  spare  the 
stomach  and  intestines  as  much  as  possible.  The  iodides  should  be  com- 
bined with  the  mercurial  treatment  in  mild  doses  and  pushed  with  cau- 
tion, largely  diluted  with  water. 

Mucous  patches  and  ulcers,  whenever  they  occur,  demand  absolute 
cleanliness,  washing  with  green  soap  and  warm  water,  and  careful  drying. 
The  surfaces  may  then  be  dusted  with  powdered  calomel,  iodoform,  or 
nosophen. 

For  ulcers  within  the  rectum  suppositories  of  iodoform,  from  four  to 
eight  grains,  should  be  inserted  once  or  twice  a  day.  For  sluggish  or 
phagedenic  ulcers  antinosin,  the  sodium  salt  of  nosophen,  is  applicable. 
In  syphilitic  stricture  of  the  rectum  enemata  are  better  than  laxatives. 


SYPHILIS   OF   THE   VISCERA.  309 

When  the  contraction  is  produced  by  fibroid  changes  in  the  wall  of  the  gut, 
the  bougie  is  indispensable ;  and  in  the  last  stage  of  unyielding  fibrous 
contraction  the  knife  or  electro-cautery  alone  offers  a  chance  of  cure  and 
holds  out  hope  of  comfort  to  the  patient. 

The  Peritoneum. — Syphilis  does  not  appear  primarily  in  the  perito- 
neum. In  connection  with  syphilitic  (especially  gummatous)  changes  in 
the  liver,  spleen,  intestines,  ovaries,  the  peritoneum  becomes  thickened 
and  adherent. 

The  Pancreas. — This  gland  as  a  result  of  syphilis  has  been  found  by 
Lancereaux  and  others,  after  death,  to  be  the  seat  of  connective-tissue 
infiltration  and  gummy  tumors. 

The  Liver. — The  jaundice  sometimes  attendant  upon  the  early  symp- 
toms of  syphilis  is  due  to  catarrh  of  the  bile  ducts. 

The  changes  in  the  liver  due  to  syphilis  later  in  the  disease  are  true 
to  the  two  types  of  syphilitic  tissue  alteration :  the  one  constructive — a 
diffuse,  cellular  hyperplasia,  ending  in  contraction  and  induration;  the 
other  destructive — the  gummy  tumor.  Amyloid  changes  in  the  liver  are 
also  ascribed  to  syphilis. 

Diffuse  syphilitic  hepatitis  occurs  in  a  circumscribed  form  in  the 
liver  of  adults  with  acquired  syphilis.  It  goes  on  to  final  atrophy  and 
cirrhosis,  the  cicatrix  formed  by  the  wasted  tissue  contracting  deeply  into 
the  organ  gives  it  a  nodular  and  irregular  surface,  the  liver  tissue  jutting 
out  between  the  puckered,  contracted  spots  in  a  singular  manner.  The 
tissue  in  these  limited  glandular  areas  may  be  normal,  or  in  amyloid 
degeneration. 

The  peritoneum  over  the  depressed  cicatricial  areas  occupying  the  sites 
of  old  disease  is  generally  thickened.  Sometimes  the  two  layers  of  peri- 
toneum are  adherent. 

Gummatous  hepatitis  occurs  as  a  dense,  connective-tissue,  radiate 
mass,  with  cheesy  deposits  scattered  through  it,  or  as  a  round,  cellular 
tumor,  degenerated  at  the  centre,  and  separated  from  the  liver  substance 
by  a  capsule  formed  of  condensed  connective  tissue.  Gummata  commence 
in  the  walls  of  the  vessels  between  the  lobules.  They  thus  envelop  the 
lobules,  which  they  destroy.  They  may  be  solitary  or  occur  in  great 
numbers,  and  of  varied  size,  interspersed  through  the  organ. 

Symptoms. — The  changes  in  size  of  the  liver  due  to  hepatitis  may  be 
appreciated  by  percussion.  Inequalities  due  to  extensive  cicatricial  puck- 
ering of  the  organ  may  sometimes  be  made  out  by  palpation.  Symptoms 
in  connection  with  syphilis  of  the  liver  are  very  moderate  or  absent  al- 
together, the  lesion  or  its  cicatrix  being  encountered  after  death.  Pain 
may  be  complained  of,  dull  or  severe,  sometimes  made  worse  by  pressure, 
especially  where  there  is  perihepatitis.  Jaundice  is  the  exception  rather 
than  the  rule,  but  sometimes  comes  on  and  lasts  long.  It  may  be  due  to 
pressure  of  the  enlarged  abdominal  lymphatic  glands. 


310  VENEREAL  DISEASES. 

Albuminuria  and  cachexia  often  accompany  syphilitic  degenerative 
changes  of  the  liver.  When  these  two  symptoms  coincide  with  an  irreg- 
ularity of  form  and  indurated  lumps,  or  a  fissured  edge  of  the  liver,  which 
may  be  felt,  the  diagnosis  of  syphilis  is  readily  made. 

Treatment  is  that  of  late  syphilis — a  mixed  medication  with  a  prepon- 
derance of  the  iodides,  especially  if  there  be  reason  to  suspect  that  the 
lesion  is  gummatous. 

The  Spleen. — The  common  varieties  of  textural  changes  which  are 
produced  in  the  spleen  by  syphilis  are  chronic  interstitial  infiltration  and 
gummatous  nodules.  The  former  occurs  as  a  diffuse,  connective-tissue, 
cellular  hyperplasia,  going  on  to  the  formation  of  fibrous  tissue  which 
contracts  and  leaves  depressed  spots,  with  the  peritoneum  over  them  ad- 
herent to  neighboring  organs. 

The  gummata  are  fibrous  nodules  of  varying  size,  granular  and  degen- 
erated centrally;  pinkish-gray  at  first,  finally  a  dirty  yellowish- white. 

Amyloid  degeneration  may  be  seen  in  connection  with  similar  changes 
in  the  liver  and  kidneys. 

Symptoms. — There  are  no  symptoms  of  these  lesions  other  than  the 
enlargement  of  the  spleen  due  to  syphilis  which  is  sometimes  recogniz- 
able. 

The  Thymus,  Suprarenal  Capsules,  and  Abdominal  Lymphatic  Glands. 
—The  thymus,  as  a  result  of  syphilis,  has  been  found  hardened,  en- 
larged, broken  down  centrally,  the  seat  of  diffuse  connective-tissue  hyper- 
plasia, and  of  gumma.  . 

Connective-tissue  infiltration  and  gummatous  degeneration  of  the 
suprarenal  capsules  are  met  with  in  acquired  syphilis. 

The  abdominal  lymphatic  glands  are  subject,  in  late  syphilis,  to  con- 
siderable enlargement  and  to  gummatous  deposits,  which  may  atrophy  or 
become  cheesy ;  or  may  soften  and  discharge,  generally  upon  the  cutane- 
ous surface,  leaving  ulcers  and  fistulous  channels  of  varying  extent  and 
duration.  The  pressure  of  these  larger  glands  may  interfere  with  diges- 
tion or  give  rise  to  jaundice. 

Such  glandular  swellings  may  be  diagnosticated  when  they  can  be  felt, 
and  are  best  treated  by  the  iodides,  with  a  certain  amount  of  mercury  by 
inunction. 

THE  VASCULAR  SYSTEM. 

Syphilis  of  the  Heart. — A  diffuse  pericardial  thickening  and  gumma 
of  the  pericardium  have  been  occasionally  noted  after  death. 

Diffuse  parenchymatous  myocarditis  also  occurs,  and  most  often  either 
with  the  diffuse  cellular  infiltration  or  independently  as  gumma  of  the 
muscular  structure. 

The  thick  wall  of  the  left  ventricle  is  the  most  common  seat  of  the 
deposit. 


SYPHILIS  OF  THE  VISCERA.  311 

Anatomically,  the  guinma  of  the  heart  is  a  collection  of  small  round 
cells,  encapsulated  and  yellowish- white  on  section,  often  cheesy  at  the 
centre.  If  near  the  surface,  the  pericardium  or  endocardium  over  them 
is  thickened.  They  are  often  multiple. 

A  general  weakening  of.  the  heart's  action,  without  any  valvular  irreg- 
ularity, attended  by  slight  enlargement  of  the  organ  and  dilatation  of  its 
cavities,  seems  to  be  the  only  symptom  upon  which  a  diagnosis  can  be 
based.  There  may  be  also  functional  disturbances,  such  as  palpitation, 
dyspnoea,  headache,  and  vertigo. 

The  possibility  of  embolism,  due  to  bursting  of  a  softened  gumma  into 
the  cavity  of  the  heart,  must  be  remembered. 

Treatment  is  mixed,  with  preponderance  of  the  iodides. 

Syphilis  of  the  Arteries. — The  changes  in  the  large  vessels  which  are 
most  common  are  atheromatous  deposits ;  and  these,  when  they  are  found 
in  a  syphilitic  subject  early  in  life,  before  they  can  be  accounted  for  by 
senile  changes,  are  generally  set  down  as  being  due  to  syphilis. 

A  diffuse  general  thickening  of  the  arterial  wall,  commencing  as  an 
endarteritis,  and  sometimes  going  on  to  the  extent  of  occluding  the 
lumen  of  the  vessel,  is  a  process  very  common  among  the  small  arteries 
in  syphilis,  especially  the  arteries  of  the  brain  (Heubner).  The  walls  of 
the  blood-vessels  large  and  small  are  the  common  seat  of  gummatoua 
tumors. 

As  a  consequence  of  a  syphilitic  artorial  changes  brain  symptoms  are 
not  uncommon,  due  to  a  cutting  off  of  a  portion  of  the  brain  from  its 
blood  supply  on  account  of  partial  or  entire  closure  of  the  lumen  of  an 
artery  through  thickening  of  its  walls.  Aneurisms  are  much  more  com- 
mon upon  syphilitic  patients  than  upon  others. 

There  are  no  positive  diagnostic  signs  by  which  the  syphilitic  nature 
of  a  presumed  or  a  positive  arterial  change  can  be  established.  When 
such  changes  occur  upon  a  syphilitic  subject,  a  mixed  treatment,  with  a 
preponderance  of  the  iodides,  is  indicated.  The  effect  of  treatment  upon 
arterial  lesions  is  not  always  brilliant,  but  often  it  is  of  enough  value  to 
make  it  well  worth  while  to  push  it  with  firmness  and  continue  it  with 
patience. 

The  effect  of  syphilis  upon  the  veins  is  quite  similar  to  that  produced 
upon  the  arteries  in  both  early  and  late  stages. 


CHAPTER  XIV. 

SYPHILIS  OF  THE  NERVOUS   SYSTEM. 

SYPHILIS  of  the  nervous  system  has  in  large  part  passed  from  the  do- 
main of  syphilography  to  that  of  nervous  diseases;  and  to-day  the  patient 
with  nervous  syphilis  turns  instinctively  to  the  neurologist.  The  subject 
is  too  extensive  to  receive  in  this  work  the  full  attention  it  merits ;  an  en- 
deavor will  be  made,  however,  to  give  a  brief  exposition  of  the  most  im- 
portant facts. 

Causation. — Certain  points  in  the  etiology  of  nervous  syphilis  deserve 
mention.  It  is  now  known,  contrary  to  the  older  teachings,  that  the 
nervous  system  is  attacked  most  frequently  within  'the  first  three  years 
after  the  original  infection.  A  considerable  number  of  cases  occur  within 
six  months  of  the  chancre.  After  ten  years  the  danger  becomes  much 
less.  The  most  systematic  and  careful  treatment  in  the  early  stages  does 
not  procure  absolute  immunity  for  the  nervous  system.  It  seems  prob- 
able, however,  that  thorough  treatment  diminishes  the  danger ;  and  this 
statement  receives  some  support  from  the  currency  of  the  theory  that 
nervous  symptoms  develop  most  frequently  when  the  early  general  symp- 
toms were  slight  and  transient — in  other  words,  in  the  cases  in  which 
treatment  is  most  apt  to  be  neglected.  There  is  little  authority  for  the 
belief  that  the  nervous  system  is  involved  with  special  frequency  when 
the  chancre  is  extra-genital.  It  has  been  estimated  that  of  all  syphilitics, 
from  one  and  one-half  to  two  and  one-half  per  cent  develop  lesions  in  the 
nervous  system,  exclusive  of  those  of  locomotor  ataxia  and  general  paresis. ' 

Alcoholism,  lead  poisoning,  fatigue  and  over-exertion,  undue  exposure 
to  the  sun  or  high  degrees  of  heat  are  among  the  most  important  exciting 
causes.  Brain  syphilis  is  especially  frequent  in  persons  of  unusual  intel- 
lectual activity ;  and  in  the  so-called  Bohemians,  who  lead  lives  of  irregu- 
larity or  excess. 

When  the  affection  of  the  nervous  system  is  hereditary,  it  usually 
appears  in  the  first  two  years  of  life,  though  it  may  do  so  at  later  periods. 

Pathology. — The  anatomical  characteristics  of  syphilis  of  the  central 
nervous  system  are  changes  in  connective  tissue  and  in  the  blood-vessels. 
They  sometimes  originate  in  the  surrounding  bones  and  extend  to  the 
brain  or  spinal  cord ;  more  frequently,  however,  in  the  nervous  system  it- 

1  A  percentage  which  to  the  authors  seems  excessively  high. 


SYPHILIS   OP  THE  NERVOUS   SYSTEM. 


313 


self.  In  connective  tissue  they  appear  as  collections  of  round,  polyhedral, 
and  branching  cells,  which  may  be  diffused  or  gathered  together  in  masses. 
These  masses  are  microscopic,  or  appear  as  very  small  dots,  or  may  at- 
tain the  size*of  large  tumors.  They  are  the  gummata.  They  are  soft, 
yellowish,  poorly  supplied  with  blood-vessels,  and  have  the  tendency  to 
central  necrosis.  The  changes  in  the  blood-vessels  are  most  important  in 
the  arteries.  Their  external  coats  are  thickened  and  infiltrated  with 
round  cells,  often  collected  as  minute  gummata.  The  endothelial  cells  of 
the  intima  proliferate,  encroaching  upon  or  obliterating  the  lumen  of  the 


FIG.  103.— Cerebral  Syphilis.    The  upper  short  line  points  to  an  eroded  aneurism  of  the  basilar  artery. 

vessel  (obliterating  endarteritis).  This  affection  of  the  arteries  may  be 
limited  to  the  small  vessels  in  the  immediate  vicinity  of  the  gummatous 
deposit,  or  it  may  involve  large  and  important  trunks  which  are  adjacent. 
It  also  occurs  in  the  larger  vessels  of  the  brain,  especially  in  the  mid- 
dle cerebral,  as  an  independent  and  primary  affection,  constituting  pri- 
mary cerebral  arteritis,  perhaps  the  most  important  form  of  nervous 

syphilis. 

These  pathological  products  may  be  circumscribed  or  scattered  through- 
out the  cerebrospinal  axis.  They  have  the  tendency  to  spread,  causing 
adhesions  of  the  membranes  to  each  other  and  to  the  surrounding  bones, 
and  to  the  nerves.  Most  frequently  the  new  tissue  involves  the  meninges 
primarily— the  internal  surface  of  the  dura  and  the  meshes  of  the  pia 
especially.  In  the  brain  the  pia  is  affected  most  frequently  at  the  base, 


314 


VENEREAL.  DISEASES. 


the  space  bounded  in  front  by  the  optic  chiasm,  behind  by  the  pons,  and 
at  the  sides  by  the  crura.     This  is  the  basal  meningitis.     The  internal 
surface  of  the  dura  suffers  chiefly  over  the  convexity.     This  occurs  as  a 
local  or  diffuse  pachymeningitis.     Solitary  gum- 
mata  also  proceed  from  the  dura. 

The  primary  involvement  of  the  internal 
parts  of  the  brain  is  more  unusual.  Still,  soli- 
tary gummata  occur  in  the  white  matter  of  the 
hemispheres,  in  the  basal  ganglia,  and  (infre- 
quently) in  the  cerebellum. 

In  the  spinal  cord,  the  commonest  mani- 
festation of  syphilis  is  a  meningomyelitis  of 
the  dorsal  region.  Others  are  gummata  of  the 
internal  surface  of  the  dura  and  cervical  pachy- 
meningitis. Solitary  gummata  of  the  cord  are 
rare.  The  blood-vessels  in  the  neighborhood  of 
the  gummatous  deposits  are  always  involved; 
but  primary  spinal  arteritis  is  very  much  less 
common  than  the  cerebral  form.  The  cranial 
nerves  are  usually  affected  by  extension  of  a 
surrounding  meningitis.  The  existence  of  peri- 
pheral neuritis  due  to  syphilis  is  doubtful.  In 
addition  to  these  changes  wrought  by  syphilis 
in  the  central  nervous  system,  of  an  inflamma- 
tory and  comparatively  gross  character,  are 
atrophies  and  dystrophies  of  the  ganglion  cells. 
Of  these  latter  little  is  known. 

Syphilis  acts  upon  the  central  nervous  system 
in  three  ways :  First,  the  effect  on  the  organ- 
ism of  the  poison  itself,  the  reaction  to  which 
is  shown  by  the  pathological  alterations  in  con- 
nective tissue,  blood-vessels,  and  nerve  cells. 
Of  this  we  know  very  little.  Second,  the  newly 
formed  tissue  acting  as  a  foreign  body,  dis- 
turbing the  function  of  conducting  paths  and 
of  nerve  cells.  These  effects  are  generally  not 
complete,  though  in  the  case  of  large  gummata 

they  may  be  serious  or  fatal.  The  third  and  most  important  effect  of 
syphilis  upon  the  central  nervous  system  is  obtained  through  the  arteries. 
Anaemia  of  important  parts  of  the  brain  is  brought  about  by  narrowing  of 
the  nutrient  vessel  through  its  thickened  intima  or  by  thrombosis.  If 
the  circulation  be  not  completely  shut  off,  or  if  it  be  quickly  resumed, 
complete  restoration  of  the  affected  brain  region  is  possible.  But  when 
the  anaemia  is  complete  or  long  continued,  the  tissues  soften  and  disinte- 


Fio.  104.— Gumma  of  the  Dura 
Slater  of  Spinal  Cord. 


SYPHILIS  OF  THE   NERVOUS  SYSTEM.  315 

grate,  a  condition  from  which  repair  is  impossible.  In  a  small  propor- 
tion of  cases  aneurisms  form  which  may  rupture.  The  basilar  artery 
is  the  most  frequent  site  (Fig.  103). 

CEREBRAL  SYPHILIS. 

General  Symptoms. — Certain  general  symptoms  are  found  more  or  less 
constantly  in  all  varieties  of  brain  syphilis,  and  they  are  in  many  ways 
characteristic.  The  mental  state,  while  it  may  be  maniacal  or  comatose 
or  normal,  is  often  that  of  inattention,  of  sleepiness,  or  dreaminess.  The 
patient  hears,  understands,  and  can  answer ;  but  he  is  quiet  and  sleepy 
and  uninitiative ;  he  is  subconscious  and  sleepy  rather  than  stupid. 
Headache  is  an  almost  constant  symptom.  Its  location  and  character  vary 
with  the  anatomical  lesion,  but  it  is  almost  always  worse  at  night.  The 
condition  of  the  pupils  may  be  of  great  assistance  in  diagnosis.  They  are 
often  unequal  in  size,  although  both  respond  to  light.  In  other  cases 
there  is  the  Argyll-Robertson  pupil,  i.e.,  response  during  accommodation, 
but  not  to  light.  In  other  cases  all  pupillary  responses  are  lost. 

In  addition  to  these  general  symptoms  there  may  be  those  common  to 
any  brain  disease.  Thus  vomiting,  dizziness,  epileptic  attacks,  etc.,  are 
frequently  met  with.  Objective  sensory  symptoms  are  rare.  The  patient 
may  complain  of  numbness  or  tingling  down  one  side,  but  it  is  not  often 
that  anaesthesia  is  demonstrable. 

A  distinguishing  characteristic  of  all  the  symptoms  of  cerebral  syphilis 
is  their  fluctuation.  They  become  worse  and  better  by  turns ;  they  ad- 
vance and  retreat ;  they  have  a  strong  tendency  to  relapse. 

The  special  clinical  forms  under  which  brain  syphilis  manifests  itself 
are  in  many  ways  characteristic  and  cleanly  cut.  But  it  must  be  re- 
membered that  syphilis  may  attack  the  brain  in  a  variety  of  ways ;  that 
the  pathological  process  may  be  slight  and  limited,  or  extensive  and  widely 
disseminated ;  and  that  the  ultimate  effects  of  the  poison  are  imperfectly 
understood.  Thus  one  of  the  more  sharply  defined  clinical  types  of  brain 
syphilis  may,  and  frequently  does,  complicate  another,  thus  creating  a 
picture  of  considerable  complexity ;  or  symptoms  of  brain  syphilis  may 
be  complicated  by  those  referable  to  the  spinal  cord.  On  the  other  hand, 
the  fact  that  the  brain  is  invaded  may  be  shown  by  one  symptom  only, 
viz.,  by  a  cranial-nerve  palsy,  by  sensations  of  numbness  and  tingling,  or 
by  momentary  aphasia  or  loss  of  power  in  a  limb.  Finally,  certain 
chronic  nuclear  degenerations,  such  as  ophthalmoplegia,  or  certain  affec- 
tions of  the  cortex,  such  as  general  paresis,  while  clinically  related  to 
syphilis,  are  yet  to  be  proved  to  be  certainly  of  syphilitic  origin. 

If  these  limitations  are  borne  in  mind,  the  following  descriptions  of 
clinical  types  will  be  found  to  cover  most  of  the  cases  commonly  met  in 
practice. 

Basal  Meningitis. — The  earliest  symptom  of  this  affection  is  headache. 


316  VENEREAL  DISEASES. 

It  is  always  severe,  becoming  so  intense  at  night  that  sleep  is  impossible 
or  seriously  interfered  with.  It  is  referred  especially  to  the  front,  sides, 
and  top  of  the  head.  It  is  paroxysmal  in  character.  The  mental  state 
varies.  In  acute  cases  there  is  great  restlessness  and  often  active  and 
noisy  delirium,  which  may  pass  into  coma.  In  chronic  cases,  which  are 
more  common,  there  is  the  characteristic  sleepiness  and  inattention. 
Vomiting  is  sometimes  present.  Dizziness  is  frequent.  General  convul- 
sions indicate  a  severe  affection.  Local  twitchings  or  convulsions  in 
muscles  partly  paralyzed  sometimes  occur.  Fever  is  present  sometimes 
in  acute  cases,  though  it  is  generally  not  high  except  in  terminal  stages. 
Extreme  thirst  is  often  complained  of  and  polyuria  is  a  frequent  symp- 
tom. The  urine  may  contain  sugar.  All  these  symptoms  oscillate  in 
their  severity,  and  one  or  another  is  at  times  the  more  prominent. 

The  almost  constant  location  of  basilar  meningitis  in  the  middle  fossa 
of  the  skull  produces  important  symptoms  referable  to  the  cranial  nerves, 
to  the  cerebral  peduncles,  and  to  the  arteries  making  up  the  circle  of 
Willis.  The  syphilitic  process  may  affect  the  nerves  by  compressing 
them ;  more  frequently  it  extends  to  the  connective  tissue  of  the  nerve 
itself,  thus  setting  up  a  neuritis.  There  is  a  great  difference,  however, 
as  to  the  liability  of  individual  nerves.  The  olfactory  is  rarely  involved, 
although  loss  of  its  function,  anosmia,  usually  bilateral,  is  sometimes  ob- 
served. The  optic  nerve  is  frequently  implicated.  The  ophthalmoscope 
shows  an  optic  neuritis,  usually  bilateral,  although  generally  more  pro- 
nounced in  one  eye  than  the  other.  Or  there  may  be  a  simple  optic 
atrophy.  Disturbances  of  vision  dependent  upon  disease  of  the  optic 
nerve  occur  in  the  form  of  hemianopsia,  of  concentric  limitation  of  the 
visual  fields,  or  of  diminution  in  the  acuity  of  central  vision. 

Nerves  of  the  Extrinsic  Eye  Muscles. — Oculomotor  palsies  are  the 
most  constant  localizing  symptoms  of  basilar  meningitis.  They  are,  in 
the  great  majority  of  cases,  unilateral.  When  occurring  on  both  sides, 
the  paralysis  is  more  severe  on  one  side  than  on  the  other.  They  cause 
double  vision  and  are  responsible  to  some  extent  for  dizziness  and  un- 
certainty of  gait.  All  have  this  in  common,  that  they  undergo  fluctua- 
tions. They  may  appear  suddenly  and  get  very  much  worse  or  very 
much  better  in  a  short  space  of  time.  None  can  be  regarded  as  incurable 
if  improvement  begins  soon  enough  after  its  first  appearance. 

The  third  nerve  is  probably  affected  more  frequently  than  any  other 
by  syphilis.  The  difference  in  the  size  of  the  pupils  and  the  loss  of  pu- 
pillary reflexes,  already  mentioned,  are  due  to  lesions  in  its  fibres  or  in 
its  nuclei.  In  addition,  palsies  in  the  muscles  which  it  supplies  are  very 
common.  The  nerve  may  be  totally  deprived  of  function,  so  that  the 
external  rectus  and  superior  oblique  are  the  only  functionating  muscles  left. 
Under  such  circumstances  there  are  ptosis,  a  marked  external  squint, 
and  the  pupil  is  dilated.  The  patient  cannot  turn  his  eye  much  farther 


SYPHILIS   OF   THE   NERVOUS   SYSTEM.  317 

outward  than  it  is  held  by  the  tonic  contraction  of  the  external  rectus. 
More  frequently  there  is  paresis  rather  than  paralysis  in  all  the  muscles 
supplied  by  the  nerve,  so  that  movements  can  be  performed,  though  im- 
perfectly ;  or  one  muscle  may  be  much  more  profoundly  affected  than  the 
others.  Thus  there  is  often  a  marked  ptosis  without  serious  affection  of 
the  muscles  of  the  eyeball.  Third-nerve  paralysis  is  frequently  ushered 
in  by  ptosis,  the  paralysis,  if  it  extends,  involving  other  muscles  later. 
It  often  exists  as  the  only  cranial-nerve  lesion. 

Isolated  paralysis  of  the  fourth  nerve  (superior  oblique)  is  very  un- 
usual, although  it  does  occur.  The  sixth  nerve  (external  rectus),  on  the 
other  hand,  suffers  frequently,  either  alone  or  in  combination  with  other 
nerves. 

It  is  very  rare  for  all  the  oculomotor  nerves  of  the  eye  to  be  involved 
together.  In  such  cases  the  lesion  is  usually  chronic,  acting  on  the 
nuclei  rather  than  on  the  nerve  trunks. 

Fifth  Nerve — The  trigeminus  is  among  the  more  infrequent  of  cranial 
nerves  stricken  by  syphilis.  Paralysis  of  it  occurs,  however,  either  alone 
or  in  combination  with  other  palsies ;  it  is  almost  always  limited  to  one 
side.  The  sensory  symptoms  are  the  most  prominent.  There  is  dimin- 
ished sensibility  or  anaesthesia  in  the  distribution  of  the  nerve.  This 
may  result  in  ulceration  of  the  cornea,  through  the  lodgment  of  foreign 
bodies.  There  may  be  typical  trigeminal  neuralgia.  Involvement  of  the 
motor  root  is  much  less  common.  It  manifests  itself  by  less  power  in  the 
muscles  of  mastication  on  the  affected  side. 

Seventh  Nerve. — One-sided  facial  paralysis  is  a  common  symptom  of 
basal  syphilis.  The  nerve  is  usually  affected  after  its  exit  from  the  pons, 
and  the  paralysis  therefore  has  the  characteristic  of  a  peripheral  paralysis. 
It  is  usually  not  complete  and  the  electrical  reactions  show  a  diminution, 
rather  than  a  loss  of  faradic  excitability.  The  acoustic,  the  glosso-pha- 
ryngeal,  the  vagus,  the  accessorius,  and  the  hypoglossus  nerves  are  hardly 
ever  affected  by  basal  syphilis. 

Peduncular  Symptoms. — Associated  with  the  cranial-nerve  affections 
of  basal  meningitis  there  is  frequently  a  loss  of  power  in  the  limbs  of  one 
side,  due  to  affection  of  one  of  the  cerebral  peduncles.  This  loss  of 
power  appears  as  a  weakness  rather  than  as  a  complete  paralysis.  The 
hand  is  clumsy,  unwieldy,  and  weak  rather  than  powerless;  the  leg  is 
dragged  and  the  patient  limps,  though  he  can  still  use  the  leg  for  getting 
about.  This  involvement  of  motion  is  usually  of  the  spastic  type,  with 
increased  tendon  reflexes.  It  may  be  due  to  the  pressure  of  small  gum- 
mata  upon  one  of  the  cerebral  peduncles  or  the  pons,  or  to  arterial  dis- 
ease. Its  arterial  origin  will  be  considered  later. 

The  gumrnata  are  extensions  of  the  meningitis  along  the  pial  septa 
which  dip  in  between  the  nerve  fibres  and  compress  them. 

As  in  this  situation  the  motor  tract  is  as  yet  uncrossed,  peduncular  or 


318  VENEREAL,   DISEASES. 

pontine  paralysis  shows  itself  on  the  side  opposite  the  lesion.  But  the 
cranial  nerve  injured  by  the  same  focus  of  disease  has  already  made  its 
exit  from  the  brain  axis,  so  that  its  paralysis  is  on  the  same  side  as  the 
lesion.  Consequently  the  clinical  picture  is  that  of  crossed  hemiplegia  or 
paralysis  of  the  limbs  of  one  side,  with  paralysis  of  one  or  more  cranial 
nerves  on  the  opposite  side.  Such  a  disposition  is  the  general  rule.  It 
has,  however,  occasional  exceptions. 

Arterial  Symptoms. — The  large  arteries  are  frequently  involved  in 
basal  meningitis.  Arteritis  in  the  vessels  in  the  neighborhood  of  the 
meningitis  develops  simultaneously  with  the  inflammation  of  the  mem- 
branes, or  else  occurs  as  a  direct  extension  of  it.  In  other  cases,  a  large 
artery  at  some  distance  from  the  meningeal  focus  becomes  diseased. 
When  the  large  arterial  trunks  are  affected,  the  aspects  of  the  case  are 
much  more  serious,  for  the  patient  is  then  exposed  to  the  danger  of  apo- 
plectic symptoms.  It  will  be  more  convenient  to  consider  the  symptoms 
under  the  description  of  primary  arteritis.  It  is  sufficient  here  to  say 
that  every  patient  with  basal  meningitis  is  exposed  to  arterial  complica- 
tions, and  especially  to  thrombosis  or  aneurism  of  the  basilar  and  middle 
cerebral  arteries.  These  are  accidents  of  the  later  periods  of  the  disease. 

Course. — Basal  meningitis  is  as  a  rule  a  chronic  affection.  Sometimes 
the  disease  takes  a  rapid  and  stormy  course,  with  intense  headaches, 
vomiting,  fever,  convulsions,  and  rapidly  appearing  paralysis,  ending  in 
death  perhaps  in  a  few  weeks.  But  such  cases  are  unusual.  Generally, 
one  or  two  symptoms  appear  at  a  time,  and  go  along  with  remissions  and 
exacerbations,  until  recovery  begins  or  until  other  symptoms  are  added  as 
the  patient  gets  worse.  It  may  thus  last  for  several  months  or  a  year. 
It  may  be  terminated  at  any  time,  though  generally  not  until  it  has  existed 
for  several  months,  by  an  apoplectic  attack.  Cases  of  long  standing  de- 
velop greater  or  less  degrees  of  dementia. 

PRIMARY  SYPHILITIC  ARTERITIS. 

This  term  applies  to  the  cases  of  cerebral  syphilis  in  which  arterial  dis- 
ease forms  the  first  and  most  important  lesion.  It  is  extremely  common. 
It  may  be  widely  distributed  throughout  the  cerebral  arteries,  causing 
symptoms  of  general  mental  impairment.  Its  most  conspicuous  manifes- 
tations, however,  result  from  the  predominance  of  the  affection,  or  a  com- 
plication of  it,  in  some  large  and  important  vessel,  causing  impairment  or 
loss  of  one  or  more  special  brain  functions.  They  result  from  a  gradual 
closure  due  to  obliterating  endarteritis,  or  to  a  more  sudden  one,  due  to 
thrombosis.  Thus  there  may  be  monoplegia  or  hemiplegia,  numbness 
and  tingling  in  limited  areas  or  in  a  whole  side  of  the  body,  muscular 
twitchings,  epileptiform  attacks,  dizziness,  all  the  varieties  of  aphasia, 
hemianopsia,  etc. 


SYPHILIS   OF   THE   NERVOUS  SYSTEM.  319 

The  symptoms  may  be  ushered  in  suddenly,  without  warning,  the 
patient  having  considered  himself  in  perfect  health,  or  there  may  be  a 
period  of  weeks  or  months  of  vague  warnings,  such  as  slight  numbness 
down  one  side,  or  twitchings,  or  difficulty  in  speech,  or  weakness  in  an 
arm  or  leg,  or  attacks  of  dizziness ;  or,  if  the  arterial  disease  complicates 
some  pre-existing  condition,  it  will  have  been  preceded  by  symptoms  of 
it.  When  the  symptoms  come  suddenly,  the  picture  is  that  of  apoplexy. 
There  may  be  an  initial  coma  lasting  usually  not  over  a  few  hours,  though 
the  patient  may  die  in  it.  Or,  instead  of  coma,  there  may  be  drowsiness 
or  a  sudden  violent  pain  in  the  head,  or  great  dizziness,  or  simply  a  con- 
dition of  mental  confusion.  Then  follow  the  special  localizing  symp- 
toms, such  as  paralysis  (hemiplegia  usually),  local  spasms,  aphasia,  etc. 
Sometimes  coma,  or  mental  symptoms,  exist  without  any  localizing  signs. 
More  frequent  than  these  cases  with  apoplectiform  development  are  those 
in  which,  during  a  period  of  headache  and  mental  dulness  lasting  several 
weeks  or  more,  there  gradually  appear  special  symptoms  to  indicate  a 
partial  closure  of  some  important  artery. 

The  diagnosis  of  syphilis  of  the  cerebral  arteries  is  of  greatest  impor- 
tance, especially  in  the  cases  which  come  on  gradually.  It  usually  oc- 
curs in  young  adults.  Probably,  when  heart  diseases  are  eliminated, 
eighty  per  cent  of  all  cases  of  apoplexy  occurring  under  forty  years  of 
age  are  syphilitic  in  origin.  The  headache  is  distinguished  from  other 
headaches  in  being  worse  at  night.  It  is  severe,  though  less  severe 
than  that  of  basal  meningitis.  The  individual  symptoms  are  usually  im- 
perfect in  their  development.  Thus  the  paralysis,  though  perhaps  com- 
plete at  first,  usually  improves  very  rapidly.  In  chronic  cases  there  is 
paresis  rather  than  paralysis.  The  symptoms  may  also  be  paroxysmal 
in  character,  worse  and  better  on  successive  days. 

The  two  affections — basal  meningitis,  with  its  frequent  complication 
of  arterial  disease,  and  primary  arteritis — are  the  most  frequent  and  in 
general  the  most  clearly  defined  clinical  types  of  cerebral  syphilis.  They 
may  perfectly  well  be  complicated  by  syphilitic  lesions  elsewhere  in  the 
brain.  Thus  a  basal  meningitis  may  extend  to  the  cortex,  or  may  exist 
contemporaneously  with  a  generalized  or  localized  cortical  meningitis. 
In  some  cases,  however,  isolated  syphilitic  lesions  exist  independently  of 
either  of  the  two  commoner  affections.  Of  these  the  most  frequent  are 
meningitis  over  the  hemispheres  and  gummata. 

CORTICAL  MENINGITIS. 

This  generally  begins  in  the  dura,  extending  to  the  pia,  and  then  in- 
volving the  subjacent  brain  substance.  It  may  be  either  generalized  or 
localized. 

1.  General  cortical  meningitis  and  meningo-encephalitis  due  to  syph- 


320  VENEREAL   DISEASES. 

ills  presents  itself  under  the  clinical  form  of  headaches,  dizziness,  of  gen- 
eral impairment  of  the  intelligence,  often  going  on  to  dementia.  Localiz- 
ing signs,  due  to  the  meningitis  itself,  are  not  prominent.  The  condition 
is,  however,  generally  complicated  by  disease  in  the  cerebral  blood-vessels, 
or  it  may  take  the  form  of  pachymeningitis  interna  heemorrhagica.  Under 
such  circumstances  its  naturally  chronic  course  may  be  interrupted  by  suc- 
cessive apoplectic  attacks. 

2.  Localized  cortical  meningitis  and  meningo-encephalitis  are  more 
acute  than  the  preceding.  They  are  frequently  situated  over  the  motor 
area  and  parietal  lobes,  and  consequently  such  localizing  symptoms  as 
paralysis,  Jacksonian  epilepsy,  aphasia,  etc.,  are  common.  The  headache 
is  localized  to,  or  at  least  more  intense  in,  the  affected  area,  and  here  also 
there  is  tenderness  on  percussion  over  the  skull.  Optic  neuritis  may  be 
present,  though  this  is  not  the  rule. 

The  extent  of  the  pathological  process  varies  greatly,  and  consequently 
the  general  symptoms  of  brain  disease,  such  as  vomiting,  dizziness,  etc., 
are  not  the  same  in  all  cases.  If  the  process  remains  localized  and  uncom- 
plicated, the  prognosis  is  relatively  good. 

Gummata. — Gummata  of  the  brain  may  occur  as  extensions  of  local 
meningitis  or  may  exist  as  isolated  tumors  in  the  hemispheres  or  the 
basal  ganglia.  They  are  rare  in  the  cerebellum.  They  may  be  single  or 
multiple,  large  or  small.  Their  symptomology  is  that  of  brain  tumors  in 
general,  with  the  special  characteristics  peculiar  to  brain  syphilis. 

Syphilis  and  General  Paresis.— General  paresis,  either  because  it  is  now 
recognized  more  readily,  or  else  by  reason  of  the  excessive  strain  modern 
times  put  upon  the  nervous  system,  has  come  to  be  a  disease  of  frequency 
and  importance,  especially  in  large  cities.  Syphilis  certainly  plays  an 
important  part  in  its  causation.  While  statistics  vary  as  to  the  frequency 
with  which  the  brain  degeneration  is  preceded  by  the  venereal  disease, 
all  agree  that  it  is  great.  The  clinical  relationship  of  the  two  diseases, 
however,  is  not  fully  substantiated  by  post-mortem  evidence,  for  the  brain 
of  a  general  paralytic  does  not  present  the  histological  anomalies  most 
characteristic  of  syphilis ;  and  the  most  expert  pathologist,  simply  from 
the  examination  of  such  a  brain,  could  not  say  whether  the  patient  had 
had  syphilis  or  not.  On  the  other  hand,  the  pathological  changes  found 
in  general  paresis  have  nothing  to  indicate  that  syphilis  might  not  have 
caused  them. 

The  most  rational  view  is  that  syphilis  is  intimately  concerned  in  the 
production  of  general  paresis,  probably  through  the  agency  of  a  late  (para- 
syphilitic)  toxin. 

SPINAL  SYPHILIS. 

Syphilis  attacking  the  spinal  cord  has  many  of  the  peculiarities  already 
mentioned  under  brain  syphilis.  The  symptoms  vary  from  time  to  time 


SYPHILIS   OF   THE  NERVOUS   SYSTEM.  321 

and  are  prone  to  relapse.  Many  of  them  are  incomplete,  in  the  early 
stages  at  least.  Thus,  the  affection  of  motor  power  is  apt  to  be  in  the 
form  of  paresis,  rather  than  paralysis ;  one  side  is  usually  involved  more 
than  the  other;  sensory  symptoms  take  the  form  of  numbness  and  ting- 
ling and  a  slight  blunting  of  cutaneous  sensibility  rather  than  of  distinct 
objective  anaesthesia.  There  is  sometimes  a  dissociation  of  sensibility  in 
spinal  syphilis,  i.e.,  there  may  be  loss  of  one  variety  of  sensation  with 
preservation  of  others.  The  most  frequent  variety  of  this  is  preserva- 
tion of  the  sense  of  touch,  with  impairment  or  loss  of  the  senses  of 
temperature  and  pain.  The  loss  of  rectal  control  is  rarely  present  early 
in  the  disease ;  retention  of  urine,  on  the  other  hand,  may  be  pronounced 
from  the  first. 

About  one-quarter  of  the  cases  of  spinal  syphilis  are  complicated  by 
brain  symptoms.  These  latter  may  be  slight  and  inconspicuous,  being 
confined  to  headache,  slight  anomalies  of  the  pupils,  the  paralysis  of  a 
single  cranial  nerve,  or  occasional  accidents  indicating  interference  with 
the  cerebral  circulation.  On  the  other  hand,  both  brain  and  cord  symp- 
toms may  be  prominent,  constituting  the  type  known  -as  cerebrospinal 
syphilis.  In  this  variety  especially  the  spinal  symptoms  indicate  multi- 
ple foci  of  disease.  The  special  characters,  association,  and  evolution  of 
the  symptoms  of  spinal  syphilis  vary  with  the  type  and  situation  of  the 
lesion  within  the  spinal  canal.  If  the  spinal-cord  lesions  are  multiple 
and  disseminated,  the  clinical  type  may  be  very  complex.  Syphilitic 
affections  of  the  vertebrae,  compressing  the  cord  secondarily,  are  very  rare. 
They  cause  a  more  sharply  localized  pain  in  the  back  and  more  pain  on 
movement  of  the  column  than  when  the  meninges  or  cord  are  involved 
primarily. 

The  most  frequent  form  of  spinal  syphilis  is  meningomyelitis.  Its 
symptoms  vary  with  its  location,  but  as  its  favorite  seat  is  in  the  mid- 
and  lower  dorsal  regions,  the  commonest  type  of  spinal  syphilis  is  spastic 
paraplegia,  with  pain  in  the  middle  of  the  back  extending  down  the  legs. 
The  course  of  the  disease  is  usually  chronic ;  rarely  is  the  onset  sudden. 
It  progresses  for  weeks  or  months  with  intervals  of  arrest  or  improve- 
ment. It  may  go  on  until  the  patient  is  totally  paralyzed,  with  contrac- 
tures,  bed-sores,  lost  control  of  the  sphincters — in  short,  to  irremediable 
and  sooner  or  later  fatal  loss  of  function  of  the  spinal  cord.  When  the 
disease  is  situated  lower  down  in  the  cord,  the  type  of  paralysis  is  flaccid 
rather  than  spastic.  When  in  the  cervical  region  it  may  give  a  picture 
similar  to  the  pachymeningitis  cervicalis  hypertrophica  of  Charcot.  Then 
both  arms  and  legs  are  affected.  They  are  weak  with  increased  tendon 
reflexes.  Numbness  and  tingling  are  felt  chiefly  in  the  arms.  Atrophy 
is  often  conspicuous  in  the  small  muscles  of  the  hand.  There  are  pain 
and  stiffness  in  the  neck. 

One-sided  lesions  cause  the  Brown-Sequard  type  of  paralysis,  i.e., 
21 


322  VENEREAL  DISEASES. 

paralysis  of  motion  on  the  side  of  the  lesion,  and  disturbances  of  cutane- 
ous sensibility  on  the  other  side. 

In  some  few  cases  a  gummatous  deposit  singles  out  some  individual 
nerve  root.  This  is  especially  frequent  with  the  first  dorsal.  It  results 
in  pain  in  the  neck,  tingling,  numbness  or  anaesthesia  and  pain  in  the 
inner  side  of  the  'arm  and  hand,  and  weakness  in  the  small  muscles  of  the 
hand.  As  the  cilio-spinal  fibres  from  the  sympathetic  pass  through  this 
root,  the  most  characteristic  manifestation  of  its  compression  are  a  loss  of 
the  cilio-spinal  reflex,  myosis,  and  a  sinking  in  of  the  eyeball,  with  nar- 
rowed palpebral  fissure. 

Finally,  in  some  cases,  ataxia  is  the  most  conspicuous  symptom. 

Solitary  gummata,  either  of  the  dura  or  of  the  cord  itself,  give  the 
ordinary  focal  symptoms  of  tumors  of  other  characters  in  these  parts. 

The  Relation  of  Syphilis  to  Locomotor  Ataxia. — Syphilis  stands  in 
about  the  same  relation  to  tabes  as  it  does  to  general  paresis.  A  large 
percentage  of  persons  who  develop  tabes  have  had  syphilis.  Yet  there  is 
nothing  in  the  pathological  anatomy  of  the  former  disease  particularly 
characteristic  of  syphilis.  Neither  are  tabetic  symptoms  cured  by  specific 
treatment.  Yet  the  great  frequency  of  the  association  of  the  two  dis- 
eases leaves  little  doubt  as  to  a  causal  relation  between  them. 

Prognosis  of  Nervous  Syphilis. — When  syphilis  attacks  the  nervous 
system,  two  questions  arise :  First,  What  are  the  chances  for  recovery 
from  the  present  attack?  and  second,  What  are  the  chances,  in  case  of 
recovery,  for  future  immunity? 

The  answer  to  the  first  question  is,  that  if  the  symptoms  are  recog- 
nized early  enough  and  vigorous  treatment  is  instituted  promptly,  the 
chances  are  very  good.  Paralysis  of  the  limbs  or  of  the  cranial  nerves, 
coma,  aphasia,  optic  neuritis,  bladder  disturbances — in  short,  any  or  all 
symptoms — may  fade  away  if  the  cause  of  them  has  not  induced  irrepar- 
able injury  to  the  essential  elements  of  the  nervous  system. 

If  hemorrhage  has  occurred,  or  if  local  ansemia  has  gone  on  to 
softening,  the  prognosis  becomes  the  same  as  for  the  conditions  due  to 
other  causes.  But  when  early  danger  signals,  such  as  slight  numbness, 
or  thickness  in  speech,  or  headache,  or  twitchings,  occurring  in  persons 
who  have  had  syphilis,  are  recognized  and  acted  upon,  they  usually  disap- 
pear under  treatment  and  are  not,  immediately  at  least,  followed  by  others 
of  more  serious  omen.  Paralytic  symptoms  due  to  pressure  of  gummatous 
deposits  may  last  for  several  weeks  or  even  months,  and  then  disappear 
entirely.  When,  however,  such  symptoms  are  the  result  of  sudden  arte- 
rial closure,  and  last  so  long  a  time,  complete  recovery  is  not  probable. 

The  prognosis  in  all  cases  of  syphilis  of  the  nervous  system  should  be 
guarded.  It  is  best  as  long  as  the  symptoms  of  arteritis  are  absent. 
But  cerebral  arteritis  may  exist  without  giving  symptoms  until  its  existence 
is  made  plain  by  thrombosis  or  hemorrhage,  which  may  terminate  the 


SYPHILIS   OF   THE   NERVOUS   SYSTEM.  323 

case  at  any  time.  A  certain  number  of  patients  do  not  respond  to  treat- 
ment, and  in  spite  of  all  that  may  be  done  the  disease  goes  on  to  cause 
permanent  disability  or  death. 

As  to  the  probability  of  second  attacks  of  syphilis  of  the  nervous  sys- 
tem, statistics  are  unreliable.  It  is  a  disease  characterized  by  relapses, 
and  there  is  a  certain  probability  that  a  person  who  has  been  affected  by 
it  once  may  be  affected  again.  There  is  no  doubt,  however,  that  many 
patients  have  one  attack  which  is  properly  treated  and  they  recover  and 
never  have  another.  The  liability  to  subsequent  attacks  is  diminished  by 
a  regular  life  and  perhaps  by  occasional  courses  of  iodide. 

Treatment. — The  treatment  of  the  various  symptoms  of  syphilis  of  the 
nervous  system  is  to  be  carried  out  in  accordance  with  the  general  princi- 
ples of  treatment  of  nervous  disease.  A  word  may  be  added  here,  how- 
ever, in  closing,  on  the  special  requirements  of  constitutional  treatment. 

This  should  be  vigorous  and  should  consist  of  inunctions,  rather  than 
of  the  internal  administration  of  mercury,  and  large  and  increasing  doses 
of  the  iodide  of  potassium.  The  inunctions  should  be  carefully  given 
every  day  for  five  days,  then  interrupted  a  day,  on  which  the  patient 
takes  a  warm  full  bath ;  then  resumed  for  five  days,  and  so  continued 
for  six  weeks,  stopping  if  the  gums  become  touched  actively.  At 
the  same  time  the  iodide  is  being  taken  in  increasing  doses.  Begin- 
ning with  fifteen  grains  three  times  a  day,  the  dose  is  rapidly  increased 
until  the  patient  is  taking  two  hundred  or  three  hundred  grains  daily.1 
Even  larger  doses  seem  successful  in  some  cases,  in  which  smaller  doses 
have  failed.  Gowers  maintains,  and,  correctly  we  think,  that  if  no  bene- 
ficial effects  of  this  mixed  treatment  are  observable  at  the  end  of  six 
weeks,  the  treatment  is  a  failure  and  should  be  abandoned. 

After  an  attack  of  nervous  syphilis  the  patient  may  advantageously 
take  two  or  three  monthly  courses  of  iodide  (gr.  xxx.-l.  daily)  every  year 
for  several  years. 

1  The  senior  author  has  given  two  ounces  and  six  drachms  each  day  for  eleven 
days. 


CHAPTER  XV. 

SYPHILIS  OF  THE  GENITOURINARY  ORGANS  IN  BOTH 

SEXES. 

THE  KIDNEY. 

SYPHILIS  is  found  in  the  kidneys  as  interstitial,  diffuse,  connective- 
tissue-cell  hyperplasia,  as  gummy  tumor,  and  as  amyloid  degeneration. 

The  diffuse  chronic  syphilitic  nephritis  is  similar  to  other  forms  of 
interstitial  nephritis.  It  is  more  likely  to  occur  in  patches,  and  upon 
seption  small  clusters  and  collections  of  cells  are  often  found  scattered 
through  it.  The  patches  of  circumscribed  disease  become  contracted  and 
condensed  with  the  progress  of  the  affection,  and  the  capsule  adheres  to 
them.  They  may  undergo  fatty  degeneration  in  certain  scattered  areas. 

Gummata  are  not  often  met  with  in  the  kidney.  In  structure  they 
resemble  gummata  of  other  organs.  They  are  always  associated  with 
more  or  less  diffuse,  parenchymatous  nephritis,  each  gumma  being  situ- 
ated in  a  condensed  band  of  connective  tissue. 

Amyloid  degeneration  of  the  kidney  has  in  it  nothing  that  is  specific. 
It  may  be  associated  with  other  lesions  due  to  syphilis,  or  exist  alone. 
In  the  latter  case  it  is  the  rule  to  find  the  liver  also  and  the  spleen  to  be 
amyloid ;  but  this  degeneration  may  exist  in  all  these  organs,  and  yet  the 
patient  have  no  syphilis.  Nevertheless,  amyloid  degeneration  of  the 
viscera  is  common  enough  in  connection  with  late  syphilitic  cachexia  to 
have  attracted  general  attention ;  and  although  the  change  is  not  in  itself 
specific,  it  is  undoubtedly  in  some  way  often  due  to  syphilis  as  a  cause. 

The  only  way  in  which  the  existence  of  syphilitic  lesions  of  the  kid- 
neys can  be  even  surmised  during  life  is  by  the  presence  of  albumin  in 
the  urine,  with  or  without  casts,  for  the  ordinary  tissue  changes  in  the 
organ  are  not  attended  by  local  pain  or  general  fever.  There  may  be 
symptoms  of  uraemia  (but  very  seldom)  and  general  anasarca  (equally 
rare),  and  often  there  are  no  symptoms  at  all,  excepting  the  presence 
of  albumin  in  the  urine,  to  declare  that  the  kidneys  are  not  sound. 

Many  cases  of  albuminuria  have  been  reported  which  have  come  on 
during  the  course  of  syphilis.  They  are  generally  unimportant,  and  get 
well  under  treatment.  It  is  certain  that  in  some  cases  slight  transient 
albuminuria  is  produced  by  the  prolonged  use  of  iodide  of  potassium  in 
large  doses.  This  ceases  on  leaving  off  the  drug. 


SYPHILIS   OF   THE   GENITO-URINARY   ORGANS   IN   BOTH   SEXES.      325 

Syphilis  of  the  ureter  does  not  seem  to  occur.  Syphilis  appears  also 
to  spare  the  bladder,  except  in  connection  with  disease  of  the  spinal  cord. 

THE  MALE  GENITALS. 

The  penis  most  often  bears  the  brunt  of  the  attack  in  primary  syphilis 
in  being  the  seat  of  chancre  and  lymphangitis.  Later  in  secondary  dis- 
ease, cutaneous  eruptions  occur  upon  it,  and  mucous  patches  and  ulcers 
within  the  cavity  of  the  prepuce  and  (very  rarely)  within  the  urethra. 
Relapsing  indurations  occur  early  and  late  in  the  disease  at  the  seat  of 
the  primary  chancre.  In  tertiary  disease,  ulcerated  subpreputial  gumma 
is  by  no  means  rare ;  a  papular  eruption  may  occur  within  the  urethra, 
giving  rise  to  a  gleet. 

Finally,  in  tertiary  disease,  gummata  occasionally  occur  in  the  cor- 
pora cavernosa,  usually  in  the  anterior  third  of  the  organ ;  they  are  very 
*rare,  and  must  be  distinguished  from  chronic  circumscribed  inflammation 
of  the  sheaths  of  the  corpora  cavernosa1  and  from  calcification  of  the 
penis. 

Gumma  of  the  corpus  cavernosum  is  a  hard,  painless,  semi-elastic 
swelling  at  first.  It  causes  deflection  of  the  penis  when  erect,  toward  the 
side  upon  which  it  is  situated,  and  to  an  extent  proportionate  to  the  size 
of  the  growth.  In  structure  it  is  like  other  gummata.  It  goes  on  to 
reach  a  certain  size,  and  then  may  soften  and  shrivel  away,  or  become 
fibrous,  or  possibly  calcify.  General  calcification  of  the  penis  occurs  in 
plates  upon  the  sheath  of  the  corpus  cavernosum  and  is  not  syphilitic. 

Chronic  circumscribed  inflammation  of  the  corpora  cavernosa  is  also 
mainly  superficial,  confined  to  the  sheath  and  underlying  tissue,  some- 
what painful  to  pressure,  often  advancing  in  one  direction  as  it  gets  well 
in  the  other,  never  by  any  chance  suppurating,  occurring  spontaneously 
or  as  a  result  of  injury,  never  due  to  syphilis. 

The  last  two  affections  are  not  in  the  least  degree  helped  by  antisyph- 
ilitic  treatment,  either  mercurial  or  by  the  iodides ;  but  gummy  tumor 
promptly  disappears  when  the  latter  remedy  is  boldly  pushed  in  large 

doses. 

The  prostate  does  not  appear  to  suffer  directly  from  syphilis.  Gumma 
in  this  region  is  possible,  but  very  rare. 

The  spermatic  cord  is  sometimes  the  seat  of  gummy  tumor,  and  the 
scrotum  a  favorite  locality  for  condylomata  and  scaly  patches  of  the  cir- 
ciuate  sort. 

i  Van  Buren  and  Keyes  :  "  Gen.-Urinary  Diseases  and  Syphilis,"  New  York,  1874, 


326  VENEREAL   DISEASES. 


THE  TESTICLE. 

Epididymitis. — During  secondary  syphilis,  in  the  earlier  months — 
three  or  four  after  chancre — there  may  appear  in  the  epididymis,  usually 
at  its  head,  on  one  or  both  sides  of  the  body,  a  round,  hard  tumor,  stand- 
ing distinct  from  the  testicle,  and  not  capped  over  it  as  in  ordinary  chronic 
epididymitis.  It  is  attended  by  a  slight  amount  of  spontaneous  pain, 
increased  by  manipulation ;  occasionally  the  swelling  is  perfectly  indolent, 
and  the  pain  is  never  so  great  as  that  experienced  in  ordinary  epididy- 
mitis. 

It  is  quite  rare.  It  always  gets  well,  never  has  been  known  to  sup- 
purate. It  is  quite  constant  in  its  appearance  at  the  globus  major,  and 
does  not  extend  to  the  body  of  the  epididymis  or  to  the  globus  minor. 
It  never  involves  the  testicle.  Later  in  the  disease  the  epididymis  is 
attacked  in  its  entirety,  generally  by  a  slow  and  indolent  syphilitic  proc- 
ess. In  the  tertiary  stage  the  enlargement  may  be  general  or  it  may  be 
nodular  and  irregular  according  to  the  distribution  of  the  hyperplastic 
gummatous  growth. 

Treatment  in  the  early  stage  is  mercurial.  In  the  advanced  period 
iodide  is  indicated  combined  with  mercury.  Local  measures  are  unnec- 
essary. 

Orchitis. — Syphilis  of  the  body  of  the  testicle  in  the  late  stages  devel- 
ops in  a  cellular  overgrowth  of  connective-tissue  elements  constituting 
diffuse  syphilitic  orchitis,  perhaps  generalized  through  the  whole  organ, 
sometimes  confined  to  a  limited  area. 

Along  with  the  other  changes  in  the  organ  the  tunica  vagiualis  becomes 
thickened,  and  its  cavity  obliterated  by  cohesion  of  its  two  surfaces,  or 
cut  up  into  partitions  by  partial  adhesions.  There  may  be  a  great  or 
small  amount  of  fluid  in  the  tunic  constituting  a  hydrocele,  which  may 
account  for  much  of  the  swelling  and  must  be  removed  before  the  actual 
contour  of  the  testicle  can  be  determined.  Often  a  hard  plate  of  over- 
hanging tissue  with  a  dense  angular  edge  can  be  felt.  This  sign  is  nearly 
pathognomonic. 

The  result  of  the  anatomical  changes  is  a  gradual,  general  enlargement 
of  the  organ  or  localized  patches  of  induration,  usually  the  former.  After 
a  time  the  organ  atrophies  and  gets  to  be  a  mere  fibrous  knot,  or,  in  any 
case,  smaller  than  it  originally  was. 

Syphilitic  orchitis  is  a  late  symptom,  rarely  appearing  during  the  first 
year  of  the  disease,  and  sometimes  coming  on  long  after  all  symptoms 
have  ceased.  It  is  also  found  in  inherited  syphilis. 

Gumma  of  the  testicle  is  recognized  as  a  distinct  tumor  perhaps  accom- 
panying the  physical  changes  indicative  of  diffuse  orchitis.  It  is  pain- 
less. The  nodule  grows  to  a  certain  size,  then  softens  centrally  and 


SYPHILIS   OF   THE   GENITOURINARY   ORGANS   IN   BOTH   SEXES.      327 

undergoes  cheesy  degeneration,  or,  infiltrating  the  tunica  albuginea,  the 
two  surfaces  of  the  tunica  vaginalis  adhere,  and  the  skin  becomes  attached 
over  the  swelling  mass,  which  opens  and  an  abscess  cavity  is  formed.  In 
some  instances  the  skin  softens,  ulcerates,  and  lets  out  the  gumma  with 
the  contents  of  the  testicle,  constituting  one  form  of  benign  fungus  of  the 
testicle. 

The  epididymis  is  sometimes  the  seat  of  gummy  tumor,  but  rarely ; 
and  the  cord  (Verneuil)  also  occasionally. 

The  symptoms  are  an  insidious  swelling-  of  one  or  both  testicles  with- 
out pain.  Generally  the  patient  finds  out  by  accident  that  one  of  his 
testicles  is  unnaturally  large  and  hard.  Squeezing  such  a  testicle  in  the 
hand  causes  the  patient  little  or  no  pain,  and  the  organ  feels  to  the  touch 
as  hard  as  wood.  It  either  preserves  its  oval  shape  when  the  epididymis 
is  indistinguishable  from  the  body  of  the  testicle ;  or  in  some  instances, 
when  the  epididymis  is  also  involved,  this  portion  may  be  felt  as  a  crest- 
ed overgrowth,  when  it  has  been  appropriately  called  the  "  clam-shell " 
enlargement.  The  cord  is  not  involved,  the  tunica  vaginalis,  instead  of 
being  obliterated,  may  be  full  of  fluid. 

The  diagnosis  of  syphilitic  testicle  is  often  difficult.  There  is  no  pos- 
sible danger  of  mistaking  it  for  gonorrhoeal  epididymitis,  or  any  other 
acute  inflammatory  affection  of  the  epididymis  or  testicle;  the  intense 
pain  in  these  maladies,  both  spontaneously  and  upon  handling  the  organ, 
excludes  syphilitic  testis  from  diagnostic  consideration  when  it  is  in  ques- 
tion. Nor  is  there  any  considerable  chance  of  the  error  of  mistaking 
chronic  epididymitis,  the  pseudo-tuberculous  testis,.  for  syphilitic  disease 
of  the  organ.  The  lumpy  condition  of  the  epididymis  capping  the  soft 
testicle  above,  or  hanging  down  as  a  cheesy  nodule  below  the  tail  of  the 
epididymis,  perhaps  softening  into  abscess  and  becoming  fistulous,  but 
leaving  the  soft,  elastic  testicle  intact  in  its  peculiar  natural  sensibility, 
may  occasionally  suggest  the  syphilitic  epididymitis,  yet  its  chronic  course 
and  peculiar  pathological  physiognomy  will  readily  distinguish  it  from 
the  syphilitic  affection. 

The  main  difficulties  in  diagnosis  of  syphilitic  testicle  are  hydrocele, 
tubercle,  and  malignant  disease  of  the  testicle.  Hydrocele  is  not  impor- 
tant. Many  syphilitic  testicles  are  so  surrounded  by  the  fluid  of  a  hydro- 
cele that  their  physical  characters  are  entirely  obscured.  In  no  case  is  it 
safe  to  decide  that  a  hydrocele  is  a  simple  matter  until  it  has  been  tapped 
and  the  testicle  examined.  If,  after  tapping,  the  physical  signs  are  those 
of  syphilis  of  the  testicle,  no  radical  treatment  of  the  effusion  in  the 
tunica  vaginalis  should  be  undertaken ;  both  because  it  is  likely  to  fail 
and  because  it  is  unnecessary,  since  antisyphilitic  treatment  will  remove 
the  effusion  together  with  the  lesion  of  the  testicle. 

Tuberculous  testis,  however,  is  often  painless ;  and  certain  stages  of 
cancer  of  the  testicle  and  of  sarcoma  are  suggestive  of  syphilis.  The 


328 


VENEREAL   DISEASES 


salient  points  of  clinical  difference  between  these  affections  can  be  best 
presented  in  the  form  of  a  short  diagnostic  table. 


DIAGNOSTIC  TABLE. 


Syphilitic  Testicle. 

Tuberculous  Testicle. 

Neoplasm. 

Previous  History.  —  S  y  p  h  i  - 

Tuberculous. 

litic. 

Commencement.  —  Genera  1  1  y 

Generally    in    the    epi- 

Always in  the  testicle. 

in  the  testicle. 

didymis. 

Growth.  —  Insidious,    often 

Slow  ;  often  lasts  many 

Sometimes  slow  ;   some- 

unnoticed,   may    last    several 

years. 

times  rapid. 

years. 

Size  and   Contour.  —  Rarely 

Often    larger    than    a 

Sometimes      enormous, 

larger  than  a  goose  egg  ;    body 

goose  egg  ;   nodular  in  the 

weighing  several  pounds; 

of  testicle   hard   and  more  or 

epididymis. 

sometimes    1  o  b  u  1  a  t  e  d  ; 

less  smooth  ;   epididymis  free, 

epididymis    becomes    in- 

sometimes   presenting    "clam- 

volved ;    veins  of  scrotum 

shell"     induration;    .scrotum 

often  enlarged. 

unchanged. 

Softening    and    Discharge.  — 

Softening    and    abscess 

Sometimes     ulceration, 

Rather  exceptional  ;  sometimes 

the  rule,  leaving  fistula. 

leaving  malignant  fungus. 

occurs,  leaving  fungus. 

Fluid  in  Tunica  Vaginalis.  — 

Not  unusual  

Unusual. 

Common. 

Pain   and   Tenderness.  —  Ab- 

Insignificant, as  a  rule. 

Present  as  a  rule,  often 

sent. 

very     sharp  ;      sometimes 

painless. 

Often  bilateral,  simultaneous 

Often  bilateral  consecu- 

Very rarely  bilateral. 

or  consecutively. 

tively. 

Sexual  Power.  —  Diminished. 

Sometimes  diminished, 

Not  impaired,  except  by 

often  not  impaired. 

size  and  pain. 

Inguinal  and  Pelvic  Glands. 

Normal  or  tender  from 

Involved. 

—  Normal. 

simple  inflammation. 

Spermatic   Cord.  —  Rarely 

Generally  involved  

Often    implicated    tow- 

implicated. 

ard  the  end. 

Seminal  Vesicles.  —  Normal  .  . 

Frequently  diseased  .  .  . 

Normal. 

Treatment.  —  C  urati  ve  . 

Q  u  i  te  unsatisfactory  ' 

Ineffective. 

cure  possible,  but  slow. 

Treatment. — Syphilitic  testicle  in  the  diffuse  form  calls  for  mercury 
as  well  as  for  iodide  of  potassium.  Local  treatment  is  of  little  or  no 
value,  but  a  suspensory  bandage  should  be  used  to  protect  the  enlarged 
organs  from  injury.  The  effect  of  treatment  is  slow,  but  should  be  per- 
sisted in  to  save  as  much  of  the  glandular  structure  as  possible  from 
atrophy.  The  iodide  should  be  pushed  up  to  large  doses  to  the  point  of 
full  tolerance  and  the  effect  watched. 

For  gummy  tumor,  the  iodides  alone  are  needed,  in  doses  as  large  as 
the  stomach  can  conveniently  manage.  A  prompt  effect  is  to  be  expected. 

THE  FEMALE  PELVIC  ORGAXS. 

The  female  genitals  are  the  common  seat  of  chancre,  erosions,  and 
mucous  patches.  Tertiary  tubercular  patches  are  found  within  the  vagina, 
and  tertiary  brawny  infiltrations  leading  to  ulcers  which  are  very  chronic 


SYPHILIS   OP  THE   GENITOURINARY   ORGANS   IN  BOTH   SEXES.      329 

in  their  course.  Gummata  in  this  region,  which  are  rare,  may  perforate 
one  or  the  other  of  the  vaginal  septa.  Lancereaux  describes  a  case  of 
gummy,  tumor  of  the  ovary  similar  to  the  same  lesion  in  the  testicle,  and 
both  he  and  Hutchinson  have  encountered  some  cases  of  imperfect  sexual 
development  in  the  female,  in  connection  with  congenital  syphilis,  making 
it  seem  probable  that  parenchymatous  ovaritis  is  possible  in  hereditary 
syphilis,  as  parenchymatous  orchitis  and  gumma  of  the  testicle  in  the 
male  are  known  to  be. 

Gummata  have  been  found  in  the  Fallopian  tubes. 

Functional  derangements  of  menstruation  are  very  common  in  women 
with  syphilis.  In  the  secondary  stage,  anaemia  leads  to  scanty  menstru- 
ation, the  relaxed  ligaments  allow  the  organ  to  become  easily  displaced. 
Hence  arise  all  sorts  of  malpositions  with  catarrhal  states  of  the  uterine 
cavity,  dysmenorrhoea,  metrorrhagia,  sterility,  hysteria,  etc. 

The  cachectic  stage  of  tertiary  syphilis  also  leads  to  uterine  derange- 
ments which  induce  premature  change  of  life. 

A  chronic  hyperplastic  infiltration  of  the  cervix  is  known  to  occur  as 
a  result  of  syphilis,  which  leads  to  a  fibroid  induration  and  stenosis  of 
the  os. 

Treatment  of  these  uterine  derangements  is  that  of  the  stage  of  syph- 
ilis in  which  they  occur,  together  with  such  local  measures  as  each  indi- 
vidual case  may  call  for.  Certain  uterine  growths  have  disappeared 
under  the  treatment  with  iodide  of  potassium  and  mercury,  but  nothing 
very  definite  is  known  of  syphilis  of  the  uterus. 


CHAPTER  XVI. 

SYPHILIS  OP  THE  EYE  AND  EAK. 

THE  skin  of  the  eyelids  is  occasionally  the  seat  of  chancre ;  patches  of 
various  kinds  of  eruption  may  come  upon  it,  mucous,  fiat  papules  are  not 
uncommon,  and  circumscribed  gummata  are  often  found  in  this  region. 

The  tarsal  cartilages  may  be  attacked  by  syphilitic  inflammation  dur- 
ing the  course  of  the  disease,  producing  considerable  infiltration  of  the  lid 
and  lasting  for  weeks  and  months. 

Upon  the  conjunctiva,  chancre  and  mucous  patches  have  been  observed. 

The  lachrymal  gland  may  become  enlarged  and  indurated  as  a  result 
of  syphilis,  but  this  condition  is  a  rare  one.  The  caruncles  are  the  seat 
both  of  chancrous  ulcerations  and  gummy  tumors. 

The  lachrymal  sac,  and  the  skin  over  it,  may  be  the  seat  of  gummatous 
deposit,  and  if  this  be  allowed  to  ulcerate,  lachrymal  fistula  may  result. 
The  nasal  duct  is  frequently  occluded  by  reason  of  ulcerative  gummatous 
changes  within  the  nasal  cavity,  especially  if  the  lachrymal  bone  be  in- 
volved in  necrosis. 

Changes  in  the  cornea  are  uncommon  in  acquired  syphilis.  With  in- 
herited disease  chronic  interstitial  keratitis  is  quite  common.  It  will  be 
described  along  with  the  other  lesions  of  inherited  syphilis.  Chronic 
diffuse  interstitial  keratitis  due  to  acquired  syphilis  in  the  adult  does 
occasionally  occur,  the  entire  cornea  being  thickened  and  obscured,  due 
to  interstitial  cellular  infiltration.  Another  form  known  as  punctate  kera- 
titis occurs  as  scattered  areas  of  corneal  opacity. 

The  sclera  is  also  sometimes  the  seat  of  syphilitic  inflammation  and 
gummatous  deposit.  Two  forms  are  spoken  of,  according  as  the  super- 
ficial or  deep  structures  are  involved,  viz.,  episcleritis  and  parenchymatous 
scleritis. 

The  treatment  of  these  affections  consists  mainly  in  the  use  of  anti- 
syphilitic  remedies,  the  protection  of  the  eye  with  smoked  glasses,  and 
general  tonics. 

In  keratitis  atropine  instillations  are  also  indicated. 

The  iris  suffers  very  often  in  acquired  syphilis. 

It  is  probable  that  at  least  half  of  all  the  cases  of  iritis  which  occur 
are  syphilitic  in  origin.  Iritis  most  often  comes  on  in  severe  cases  of 
syphilis  with  one  of  the  early  eruptions ;  particularly  is  it  apt  to  coincide 
with  a  pustular  eruption.  The  symptoms  are  exactly  the  same  as  those 


SYPHILIS   OF   THE   EYE   AND    EAR.  331 

of  acute  iritis  due  to  any  cause ;  slight  dulness  and  change  in  the  color  of 
the  iris,  more  or  less  injection  of  the  pericorneal  conjunctiva  (possibly 
chemosis),  lachrymation,  supra-orbital  pain,  generally  worse  at  night, 
and  intense  photophobia.  The  pupil  is  hazy,  and  will  not  dilate  in  the 
dark.  When  forced  to  dilate  by  the  use  of  atropine  or  duboisine,  its  mar- 
gin is  often  festooned,  it  does  not  dilate  regularly.  Plastic  exudation  of 
lymph,  effused  from  the  borders  and  posterior  surface  of  the  iris,  is  quite 
common,  by  means  of  which  adhesions  are  effected  with  the  anterior 
capsule  of  the  lens,  and  the  dilatability  of  the  pupil  is  permanently  com- 
promised. Its  opening  may  be  entirely  occluded.  A  thin,  diffused  sero- 
plastic  exudation  sometimes  fills  the  anterior  chamber  (serous  iritis). 
It  may  be  seen  to  be  absorbed  and  to  melt  away  under  treatment. 

The  simplest  form  of  iritis  occurring  early  in  the  disease  is  spoken  of 
as  plastic  iritis.  Where  the  affection  is  more  deeply  seated  and  is  accom- 
panied by  cellular  infiltration  it  is  known  as  parenchymatous  iritis.  In 
this  form  suppuration  may  occur  which  often  appears  in  scattered  nodules 
or  tubercles  upon  the  surface  of  the  iris. 

Gumma  of  the  iris  is  less  common,  but  may  be  observed  as  a  small, 
yellowish-red  papule  growing  from  the  iris.  This  may  reach  a  consider- 
able size,  fill  up  the  pupil,  and  distend  the  anterior  chamber.  It  may 
disappear  under  the  internal  use  of  the  iodide  of  potassium.  Instead 
of  growing  out  as  one  distinct  tumor,  there  may  be  several  small  gum- 
mata  upon  the  iris,  or  the  whole  muscle  may  be  diffusely  infiltrated  and 
contract  strong  adhesions  with  the  capsule  of  the  lens. 

The  ciliary  body  and  the  choroid  may  be  involved  in  inflammatory  and 
gummatous  complications  in  connection  with  syphilitic  iritis. 

Relapse  of  plastic  iritis,  especially  if  there  be  many  adhesions,  is  quite 
common,  and  these  relapses  may  continue  on  for  a  number  of  years. 
Plastic  iritis  is  often  double,  simultaneously  or  consecutively.  Gumma- 
tous iritis  is  generally  confined  to  one  side. 

Treatment.—  Iritis  when  seen  early  generally  yields  a  prompt  obedi- 
ence to  the  influence  of  mercury  or  the  mixed  treatment,  according  to  the 
stage  of  the  disease  in  which  iritis  appears.  If  the  patient  is  anaemic 
and  debilitated,  cod-liver  oil,  tonics,  change  of  air,  good  food,  etc.,  are 
all  of  the  highest  value.  The  mercury  should  be  pushed  until  the  gums 
show  its  influence  slightly. 

The  great  danger  in  iritis  is  adhesion  of  the  pupillary  margin  to  the 
anterior  capsule  of  the  lens.  If  this  occurs,  it  is  vastly  better  that  it 
should  do  so  with  the  pupil  widely  dilated;  hence  it  is  always  advisa- 
ble to  use  instillations  of  solutions  of  atropine  into  the  eye.  A  solu- 
tion of  gr.  i.-iv.  to  the  §  i.  of  distilled  water  may  be  used;  a  few  drops 
being  placed  beneath  the  lid  once  a  day,  or  oftener,  if  it  is  found  neces- 
sary, in  order  to  hold  the  pupil  dilated  to  its  greatest  extent,  and  this 
should  be  continued  until  all  photophobia  has  passed  and  all  conges- 


332  VENEREAL  DISEASES. 

tion  ceased.  The  eye  should  be  kept  closely  shaded  from  light,  but  it  is 
not  wise  to  keep  the  patient  in  the  house,  much  less  to  confine  him  to  a 
dark  room.  In  case  of  great  pain  hot  compresses  and  sometimes  leeches 
over  the  temple  are  employed. 

The  gummatous  form  of  iritis  conies  most  readily  under  the  influence 
of  the  iodides,  but  the  use  of  atropine  is  desirable  in  these  cases  as  well  as 
in  the  other  forms.  For  old  cases  when  the  pupil  is  adherent,  and  relapses 
occur,  iridectomy  is  the  remedy. 

Syphilis  of  the  ciliary  body  or  cyclitis  is  generally  observed  in  connec- 
tion with  inflammation  of  the  iris  (iridocyclitis)  or  of  the  choroid.  Gum- 
mata  have  been  known  to  occur  in  this  region. 

The  choroid  may  be  affected  by  syphilis  alone,  or  in  connection  with 
disease  in  other  structures  within  the  globe ;  it  often  participates  in  inflam- 
matory disturbances  which  primarily  involve  the  iris.  Choroiditis  dis- 
seminata,  or  plastic  choroiditis,  is  a  common  form  of  the  disease  as  pro- 
duced by  syphilis.  In  this  condition  the  ophthalmoscope  reveals,  through 
a  clouded  vitreous  humor,  small  scattered  spots  of  a  pale  color,  perhaps 
with  reddened  borders,  distributed  over  the  posterior  surface  of  the  cham- 
ber of  the  eye.  The  retinal  vessels  may  be  occasionally  seen  unchanged, 
passing  over  these  spots,  which  are  of  varied  size,  and  are  evidently  ele- 
vated exudations.  The  optic  nerve  is  congested. 

These  elevated  exudations  may  disappear  entirely  under  treatment, 
leaving  but  little  trace,  or  they  may  be  succeeded  by  small  white  atrophic 
spots  without  pigment,  except  at  their  borders,  where  there  is  an  intensi- 
fication of  pigmentation  in  the  shape  of  a  dark  line.  The  vitreous  is 
more  or  less  clouded  with  opacities.  There  is  also  a  serous  choroiditis 
resembling  serous  iritis  in  which  the  exudation  is  serous  instead  of  plastic. 
A  condition  involving  a  marked  increase  in  the  cellular  tissue,  also  seen  in 
iritis,  is  likewise  termed  parenchymatous  choroiditis. 

This  affection  is  chronic  in  character.  The  amount  of  influence  upon 
vision  is  proportionate  to  the  position  and  extent  of  the  exudative  patches, 
and  the  degree  of  atrophy  following  them.  The  course  of  the  malady  is 
very  chronic;  it  occurs  in  late  secondary  disease,  and  well  along  in  the 
tertiary  period.  Mercurial  treatment  is  appropriate,  and,  unquestionably, 
is  often  slowly  productive  of  much  good.  In  old  cases,  in  which  atrophy 
is  an  accomplished  fact  or  far  advanced,  treatment  is  of  little  or  no 
value.  Local  treatment  is  useless.  The  eyes  should  be  kept  protected 
from  strong  light. 

The  retina  also  suffers  from  syphilis.  Both  eyes  may  be  attacked 
simultaneously  or  successively.  There  is  no  outside  redness  upon  the 
conjunctiva,  no  lachrymation,  no  pain,  moderate  photophobia.  The  only 
subjective  symptoms  are,  in  the  beginning,  flashes  of  light;  later,  failure 
of  sight.  The  affection  may  get  well  and  leave  little  or  no  trace,  or 
may  lead  to  permanent  impairment  of  vision. 


SYPHILIS   OF  THE  EYE  AND   EAR.  333 

The  ophthalmoscope  reveals  a  cloudy  vitreous  and  a  retina  apparently 
obscured.  Its  outlines  are  less  distinct  than  usual,  the  retina  is  oedema- 
tous,  the  retinal  vessels,  as  well  as  the  optic  nerve,  are  hypersemic;  the 
outline  of  the  papilla  is  not  clearly  marked.  The  veins  are  full,  and  there 
may  be  hemorrhages.  9 

Retinitis  occurs  more  commonly  in  combination  with  choroiditis  when 
it  is  characterized  by  infiltration  of  the  vitreous.  In  the  forms  in  which 
the  inflammation  is  distinctly  confined  to  the  retina  itself  there  is  general 
opacity  of  this  structure  with  more  or  less  hypersemia,  oedema,  and  ecchy- 
mosis  according  to  the  intensity  of  the  inflammation.  The  finer  distinc- 
tions between  the  other  forms  of  retinitis  are  too  technical  to  come  within 
the  scope  of  this  work. 

The  treatment  of  syphilitic  retinitis  is  by  mercurials  in  moderate 
amount.  No  great  energy  of  treatment  is  called  for,  and  a  cure  may 
be  expected  if  treatment  is  applied  during  the  early  stages  of  the  ma- 
lady. The  eyes  should  be  shaded  by  colored  glasses.  The  abstraction 
of  blood,  by  occasional  leeching  of  the  temple,  has  been  recommended. 

Optic  neuritis  is  an  affection  very  common  in  syphilis  in  connection 
with  a  variety  of  lesions  of  the  brain.  It  may  also  originate  primarily 
within  the  globe  of  the  eye  independently  of  external  causes.  It  is  very 
often  found  in  connection  with  convulsive  and  paralytic  changes  due  to 
syphilis,  and  is  looked  upon  as  a  corroborative  symptom  of  great  value  in 
many  cases. 

The  symptoms  are :  diminution  of  the  field  of  vision,  in  one  direction 
or  another,  often  irregularly — a  portion,  perhaps  an  irregular  half  or  a 
quarter  of  the  field,  being  lost.  A  routine  examination  of  the  eyes  with 
the  ophthalmoscope  should  be  made  in  all  cases  of  nervous  disease  due  to 
syphilis,  especially  if  there  be  pain  in  the  head,  in  order  that  impending 
optic  neuritis  may  be  detected  early  and  loss  of  sight  warded  off. 

In  simple,  light  cases  of  optic  neuritis,  the  ophthalmoscope  shows  only 
a  little  indistinct  blurring  of  the  papilla,  a  congestion  of  the  nerve,  and 
distention  of  the  central  vessels.  In  severer  cases,  the  disc  is  greatly 
swollen,  with  irregular,  obscured  borders.  The  disc  seems  infiltrated, 
and  is  of  a  cloudy  white  or  grayish-red  color,  the  vessels  are  distended, 
irregular,  tortuous.  This  appearance  is  known  as  "  choked  disc. "  It  indi- 
cates intracranial  pressure,  as  by  a  tumor,  and  is  a  syphilitic  symptom 
only  by  coincidence.  It  occurs  equally  well  in  connection  with  tumors 
of  the  brain  due  to  other  causes.  Optic  neuritis  is  oftener  double  than 
single. 

The  treatment  of  optic  neuritis  is  the  mixed  treatment  of  tertiary 
syphilis  with  preponderance  of  the  iodides.  Local  measures  are  unneces- 
sary. The  effect  of  treatment  often  depends  upon  the  promptness  with 
which  it  is  commenced  and  its  power  to  remove  the  intracranial  lesion, 
which  has  given  rise  to  the  trouble  in  the  eye.  The  eye  symptoms  are 


334  VENEREAL  DISEASES. 

often  of  only  secondary  importance ;  but  improvement  in  the  size  of  the 
field  of  vision  and  an  arrest  in  the  progress  of  the  affection  may  be  fre- 
quently attained  by  suitable  treatment  persisted  in  for  a  considerable 
time. 

SYPHILIS  OF  THE  EAR." 

The  external  ear  is  the  seat  of  many  cutaneous  lesions  and  ulcers  in 
syphilis ;  mucous  patches  appear  sometimes  in  the  external  auditory  canal, 
and  a  peculiar  dry  scaliness  of  this  canal,  with  tendency  to  impaction  of 
cerumen,  is  quite  commonly  encountered  in  syphilitic  patients.  This 
affection  calls  for  constant  care  and  frequent  syringing  of  the  ear  to  keep 
the  passage  in  good  order  and  the  drum-head  clear  until  the  tendency  to 
dry  exfoliation  passes  away.  Improving  health,  when  the  depressing 
influence  of  syphilis  has  been  removed,  restores  the  integument  of  the 
auditory  canal  to  its  normal  condition.  Gummata  of  the  external  ear  are 
rare. 

The  middle  ear  suffers  in  various  ways  by  syphilis.  Ulcerative  and 
bony  lesions  within  the  cavity  of  the  nose  and  the  pharynx  lead  to  thick- 
ening and  inflammatory  changes  in  the  Eustachian  tube  and  its  mucous 
lining.  These  may  terminate  in  catarrhal  troubles  of  the  middle  ear 
and  consequent  impairment  of  hearing. 

Inflammation  in  the  middle  ear  generally  extends  from  syphilitic  trou- 
ble in  the  nose  or  throat.  It  may  assume  a  catarrhal  type  and  lead  to 
sclerosis  or  suppuration,  periostitis,  or  rarefying  ostitis  of  the  bony  struc- 
tures. 

The  labyrinth  is  sometimes  involved,  but  more  commonly  in  inherited 
than  acquired  syphilis. 

The  symptoms  of  middle-ear  disease  are  mainly  tinnitus  aurium  and 
impairment  of  hearing  in  various  degrees.  There  may  be  no  pain  and 
the  hearing  may  not  be  seriously  affected  until  the  disease  has  existed  for 
a  long  time.  Ulcerations  in  the  nasopharynx  accompanied  by  impair- 
ment in  hearing  should  lead  to  the  suspicion  of  catarrhal  inflammation  of 
the  middle  ear. 

The  treatment  consists  in  the  employment  of  warm  syringing,  the  ap- 
plication of  leeches  behind  the  ear,  and  inflation  of  the  tympanic  cavity. 
The  mercurials  internally  are  generally  more  effective  than  the  iodides; 
but  the  possibility  of  implication  of  bone  calls  for  the  use  of  the  last-men- 
tioned remedy,  although  not  in  very  large  doses. 

The  auditory  nerve,  the  second  branch  of  the  seventh  pair,  is  some- 
times the  seat  of  special  disease  in  syphilis,  aside  from  any  loss  of  func- 
tion due  to  disease  of  the  bones  of  the  internal  ear  or  gummy  tumor 
involving  the  nerve.  Such  essential  loss  of  function  in  the  nerve  has 
been  observed  in  the  secondary  stage  and  is  greatly  improved  by  internal 
treatment.  In  tertiary  disease  it  sometimes  comes  on  suddenly  without 


SYPHILIS  OF  THE  EYE  AND  EAR.  335 

warning,  not  attended  by  pain,  without  any  especial  symptoms  except 
that  the  patient  becomes  deaf — often  very  rapidly  so. 

If  the  cochlea  is  involved,  the  high  notes  of  the  musical  scale  are  lost 
first  (Roosa),  or  are  heard  double,  and  the  tuning-fork  on  the  forehead  ia 
heard  best  in  the  sound  ear.  Some  ringing  of  the  ear  is  complained  of, 
and  vertigo,  with  staggering,  are  apt  to  usher  in  the  disease. 

The  diagnosis  of  syphilis,  in  cases  of  deafness  coming  on  in  this  way, 
must  be  based  upon  the  history  and  concomitant  symptoms. 

The  treatment  must  be  energetic.  No  time  is  to  be  lost.  The  disease 
should  be  taken,  if  possible,  at  its  very  beginning,  and  opposed  vigor- 
ously with  specific  remedies  from  the  start.  Both  mercury  and  the  iodide 
of  potassium  should  be  used,  and  both  should  be  pushed  rapidly  to  the 
point  of  tolerance.  If  possible,  the  mercurial  bath  should  be  employed. 
Everything  in  these  cases  must  be  made  subservient  to  the  treatment. 
The  patient  should  be  confined  to  an  unirritating  diet,  give  up  business, 
and  have  his  mind  at  rest. 


CHAPTER  XVII. 

INHERITED  SYPHILIS. 

Syphilis  and  Pregnancy. — Syphilis  may  be  transmitted  by  inheritance. 
The  question  of  its  transmission  to  the  child  from  either  one  or  both 
parents  as  well  as  the  possibility  of  inheritance  in  the  third  generation 
has  already  been  discussed  (page  206) .  There  can  be  no  possible  doubt 
that  active  early  syphilis  in  the  mother  necessitates  disease  in  the  child, 
if  the  latter  comes  to  term  at  all;  while  active  early  syphilis  in  the  father 
is  not  incompatible  with  a  healthy  child,  if  the  mother  be  not  poisoned. 
After  syphilis  becomes  latent  in  the  parents,  when  they  both  appear  to  be 
healthy,  the  child  may  still  be  syphilitic,  and  repeated  successive  con- 
ceptions may  all  yield  a  diseased  product  for  a  number  of  years,  the  limit 
of  which  cannot  be  definitely  stated.  This  much,  however,  seems  certain, 
that  the  rule  is  for  syphilis  eventually  to  wear  itself  out,  and  for  syphilitic 
parents  eventually  to  produce  healthy  offspring,  provided  their  own  health 
has  not  been  seriously  and  permanently  undermined  by  syphilitic  cachexia 
or  visceral  lesions.  In  other  words,  syphilis  is  transmitted  only  as  syphi- 
lis. A  syphilitic  parent  may  produce  a  weakly  child,  because  she  has 
had  her  own  health  broken  by  syphilis ;  but  she  would  have  produced  ex- 
actly the  same  child  had  her  health  been  broken  by  want  and  privation, 
by  cancer,  by  malaria,  by  alcohol,  or  any  other  cause.  Syphilis  does  not 
change  in  type  by  transmission.  It  does  vary  greatly,  as  seen  in  the 
child,  but  it  varies  in  activity,  in  intensity,  not  in  type.  A  child  born 
to  parents  in  active  syphilis  will  probably  die,  unless  its  own  vitality  has 
been  sheltered  by  the  treatment  of  the  mother  while  it  was  in  the  foetal 
state.  A  child  born  to  parents  whose  disease  is  on  the  wane,  perhaps 
nearly  exhausted,  shows  but  few  evidences  of  disease,  and  those  per- 
haps only  during  adolescence ;  but  what  symptoms  it  does  show  bear  the 
brand  of  syphilis,  and  are  relievable,  if  at  all,  mainly  by  antisyphilitic 
treatment. 

Statistics  seem  to  show  that  about  one-third  of  the  total  number  of 
children  conceived  by  syphilitic  parents  die  in  utero,  and  of  those  which 
are  not  still-born  about  twenty-five  per  cent  succumb  to  the  disease  dur- 
ing the  first  few  months. 

Syphilitic  Abortion. — When  a  woman  is  in  active  syphilis,  she  rarely 
carries  a  child  to  term.  At  first  it  is  customary  for  such  a  woman  to 
abort  at  or  about  the  third  month  of  utero-gestation.  Such  a  woman  may 


INHERITED    SYPHILIS.  337 

have  been  poisoned  by  her  husband,  and  had  a  chancre  without  know- 
ing it. 

Should  she  become  pregnant  again,  she  will  again  abort,  but  probably 
at  a  later  month  of  utero-gestation.  Again  pregnant,  she  again  aborts ;  on 
this  occasion,  perhaps,  miscarrying  at  the  seventh  month.  The  next  at- 
tempt may  produce  a  dead-born  child,  with  its  skin  commencing  to  come 
off.  Finally  a  child  will  be  born  at  term  alive,  perhaps  plump  and  clean- 
skinned,  but  in  from  two  to  four  weeks  it  begins  to  fall  away  in  flesh,  gets 
snuffles,  sore  mouth,  eruptions,  jaundice,  and  dies;  another  child  appears 
and  dies  in  a  convulsion  after  a  few  months  of  life,  or  perishes  by  maras- 
mus in  its  second  summer.  At  last  a  fat  child  is  born  seemingly  healthy, 
but,  as  it  grows,  its  fontanelles  close  too  rapidly,  it  is  microcephalic,  looks 
like  an  old  man,  is  perhaps  very  precocious,  but  it  has  a  harsh  cry,  con- 
tracted jaws,  bad  teeth;  the  second  set  are  syphilitic  teeth.  It  has  a 
syphilitic  countenance,  and  grows  up,  perhaps,  dwarfed  or  deformed  in 
its  bones,  to  fall  a  victim,  possibly,  to  gummatous  lesions  of  the  bones, 
the  brain,  the  eye,  or  the  viscera  during  development  into  manhood. 

After  this  the  mother  will  produce  a  perfectly  healthy  child,  if  her 
own  health  be  good.  Her  subsequent  offspring  will  not  probably  be  de- 
formed. A  child  may  be  weakly,  if  the  mother  or  father,  or  both,  be  in 
poor  health,  or  from  a  variety  of  causes ;  but  if  the  parent  is  syphilitic, 
the  child  is  either  syphilitic  or  healthy,  so  far  as  the  syphilis  essentially 
has  anything  to  do  with  the  matter. 

Now,  during  all  this  time  above  detailed,  a  mercurial  treatment  given 
to  the  mother,  by  inunction  or  internally,  during  the  whole  course  or 
the  greater  part  of  her  pregnancy,  will  generally  cause  her  to  produce  a 
healthy  child— a  child  who  not  only  is  healthy  at  birth,  but  remains 
healthy,  and  does  not  require  treatment.  Treatment  rarely  has  so  good 
an  effect  if  used  in  the  first  pregnancy.  Then  the  syphilitic  poison  is  too 
strong.  A  live  child  may  be  born  reasonably  healthy,  but  its  health  is 
not  assured,  and  it  may  demand  treatment  to  preserve  it  from  injury  by 
the  development  of  hereditary  syphilis. 

Again,  if  a  mother  has  produced  a  healthy  child  under  treatment,  she 
must  go  on,  and  at  her  next  pregnancy  again  take  a  full  mercurial  course, 
although  she  may  have  had  no  symptoms  of  syphilis  during  a  number  of 
years,  or  she  will  run  the  risk  of  again  producing  a  diseased  child.  Dur- 
ing how  many  pregnancies  this  must  be  kept  up  is  not  known,  but  cases 
are  on  record  in  which  the  successful  production,  under  mercury,  of  two 
healthy  children  successively  (the  eighth  and  ninth,  all  the  previous  chil- 
dren having  died  syphilitic)  did  not  succeed  in  rendering  the  mother 
capable  of  bringing  a  non-syphilitic  child  into  the  world.  Iij  cases  of 
this  sort,  therefore,  it  will  be  wiser  to  medicate  the  mother  at  least 
through  three  successive  pregnancies  before  allowing  her  to  try  the  exper- 
iment of  passing  through  a  term  of  utero-gestation  unaided  by  drugs. 
22 


338  VENEREAL  DISEASES. 

The  cause  of  abortion  when  the  mother  is  syphilitic  is  believed  to  be 
toxins  which  are  generated  in  her  system  and  circulated  through  her 
blood  and  which  possess  varying  degrees  of  virulence  according  to  the 
stage  of  the  diesase  and  the  effect  of  treatment. 

When  the  intensity  of  syphilis  is  great  enough,  the  germ  is  incapable 
of  development  to  maturity,  and  the  foetus  dies.  This  death  of  the  prod- 
uct of  conception  is  probably  attended  by  and  due  to  alterations  in  the 
placenta  which  destroy  any  resistance  this  organ  may  exercise  against  the 
entrance  of  the  syphilitic  toxins  into  the  foetal  circulation.  The  ovum 
may  be  blasted  to  such  an  extent  that  abortion  of  a  misshapen  organized 
mass  occurs  within  a  few  months  after  conception.  The  syphilis  of  the 
parents,  under  these  circumstances,  is  too  apparent  to  need  confirmation 
by  any  fresh  proof  drawn  from  any  condition  of  the  ovum.  Attempts  at 
saving  the  foetus  must  be  made  at  each  subsequent  pregnancy,  and  the 
Chances  of  success  will  improve  very  materially  with  each  attempt. 

When  the  child  has  been  fully  formed,  and  then  dies  in  utero,  it  is 
very  uncommon  for  the  uterus  to  carry  it  to  full  term.  Abortion  usually 
occurs  about  the  sixth  month  or  sooner,  unless  inoculation  of  the  mother 
takes  place  after  impregnation,  when  it  occurs  somewhat  later. 

The  condition  of  affairs  described  above  may  certainly  be  averted  by 
treatment.  Mercurial  treatment  is  of  the  most  value.  The  iodides  have 
little  or  no  power  in  averting  the  tendency  of  syphilitic  women  to  mis- 
carry. Mercury  will  generally  do  this,  and  when  it  accomplishes  the 
result,  it  does  so  without  injury  either  to  the  child  or  to  the  mother. 

The  manner  of  giving  mercury,  under  these  circumstances,  is  unim- 
portant, provided  enough  be  given.  Inunction  is  highly  praised  by  some 
authorities. 

The  blue  mass,  which  is  an  unirritating  form  of  mercury,  is  appropri- 
ately combined  with  a  tonic  in  one  of  the  following : 

R  Pil.  hydrargyri, gr.  c. 

Ferri  sulph.  exsiccat., gr.  1. 

M.  ft.  pil.  1. 

Or— 

R  Pil.  hydrarg., gr.  c. 

Quinin.  bisulph., gr.  1. 

M.  ft.  pil.  1. 

Commencing  at  the  beginning  of  pregnancy,  one  of  these  pills  is  to  be 
used  after  each  meal  (three  a  day)  for  a  week.  Then  four  pills  a  day  are 
used  for  a  week,  then  five  pills  a  day  for  a  week,  and  so  on  until  the  med- 
icine begins  to  disagree.  When  the  mouth  becomes  a  little  touched,  all 
medication  is  suspended  for  a  week,  and  then  a  dose,  two-thirds  of  what 
was  found  necessary  to  touch  the  mouth,  is  commenced  with  and  given 
regularly.  It  may  be  alternated,  from  time  to  time,  with  a  mild  dose  of 


INHERITED   SYPHILIS.  339 

corrosive  sublimate  in  compound  tincture  of  bark.  It  may  be  intermitted 
entirely  for  a  time,  and  replaced  by  inunction  if  the  stomach  becomes 
irritated. 

Such  a  course  will  save  most  mothers  from  miscarrying.  The  chances 
of  averting  the  mishap  are  greater  the  farther  removed  the  conception  is 
from  the  chancre.  Success  or  failure  in  one  pregnancy  must  modify  tho 
treatment  of  the  next,  and  the  result  is  certain  to  be  finally  satisfactory 
to  all  concerned. 

Milk  diet,  combined  with  the  mercurial,  is  very  advantageous  in  preg- 
nancy, and  in  any  case  a  mild  diuretic  should  be  occasionally  used. 

SYMPTOMATOLOGY  OF  INHERITED  SYPHILIS. 

When  a  foetus  has  been  dead  in  the  uterus  for  some  time  it  becomes 
macerated.  The  epidermis  rises  into  large  bullae  over  portions  of  the 
body,  or  sheds  off  entirely  in  large  patches.  The  amniotic  liquid  is  more 
or  less  cloudy,  discolored,  sometimes  putrid.  In  such  children  are  found 
invariably  certain  pathological  tissue  changes  in  the  viscera  and  in  the 
bones,  particularly  the  epiphyseal  ends  of  the  long  bones.  These  changes 
are  the  same  as  those  which  are  found  (although  less  marked)  in  the 
viscera  and  bones  in  children  who  die  of  inherited  syphilis  at  varying 
periods  after  birth.  The  visceral  changes  are  much  the  same  as  those 
which  occur  in  connection  with  some  cases  of  acquired  syphilis,  the  dif- 
ference being  that,  with  inherited  disease,  visceral  lesions  are  more  com- 
mon than  in  acquired  syphilis,  and  that  they  are  more  often  of  the  diffuse 
interstitial  type  than  gumrnatous,  as  distinct  tumors.  Interstitial  hyper- 
plastic  thickening  of  the  stroma  of  the  liver  and  lungs  is  very  common  in 
inherited  syphilis — so  common  as  to  be  the  rule  in  all  cases  dying  early. 
The  thyrnus  is  quite  constantly  involved,  and  the  spleen  and  kidneys  are 
very  often  implicated.  The  ordinary  necrotic  and  carious  changes,  the 
subperiosteal  gummata,  and  the  ulcers  involving  the  bone,  already  de- 
scribed for  acquired  syphilis,  occur  also  sometimes  in  children  with  in- 
herited disease  who  survive ;  but  the  lesions  now  about  to  be  studied  are 
found  only  in  inherited  syphilis,  and  are  peculiar  to  it.  They  are  very 
constant  also,  and  it  is  said  may  always  be  found  upon  any  dead-born 
fcEtus  if  the  cause  of  its  death  has  been  syphilis. 

The  Bones  and  Joints.— The  symptoms  of  bone  syphilis  in  inherited 
disease  are  a  thickening  at  the  ends  of  the  long  bones,  sometimes  involv- 
ing the  skin  in  inflammatory  adhesion,  sometimes  attended  by  local  soft- 
ening and  suppuration,  sometimes  having  gone  on  to  a  separation  of  the 
epiphysis  from  the  shaft  of  the  bone,  and  given  rise  to  an  inability  to  use 
the  limb  (pseudo-paralysis— Parrot1).  The  bones  most  often  diseased 

1  Archiv.  de  physiol.  norm,  et  path.,  1872,  Nos.  3,  41  and  5. 


340  VENEREAL  DISEASES. 

are  the  long  bones  of  the  extremities,  the  ribs,  the  clavicles,  the  metacar- 
pal  and  metatarsal  bones.  The  lesions  are  nearly  always  symmetrical. 

All  children  with  inherited  syphilis  do  not  necessarily  suffer  with  these 
bony  changes,  or  at  least,  if  they  do,  they  grow  up  without  bea'ring  any 
evidence  in  their  bones  that  they  have  so  suffered;  but,  if  the  syphilis 
in  the  inherited  state  be  intense  enough  to  blight  the  ovum  and  cause 
the  death  of  the  foetus,  then  these  bony  changes,  more  or  less  marked, 
are  constantly  found. 

The  changes  in  the  bones  take  place  at  the  line  of  cartilaginous  junc- 
tion between  different  centres  of  ossification,  and  are  most  marked  at  the 
epiphyseal  line  of  junction  at  the  ends  of  the  shafts  of  the  long  bones 
(osteochondritis) .  Here  may  be  found  fusiform  swellings,  thickening  of 
the  bones,  and  osteophytes,  bony  overgrowths,  which  may  be  felt  through 
the  skin.  If  the  degenerative  changes  have  advanced  far  enough,  an  epi- 
physis  may  be  separated  from  its  diaphysis  without  any  preforation  of  the 
skin  or  discharge  of  necrotic  material ;  or  the  skin  may  become  adherent 
and  perforated,  allowing  the  debris  of  bony  and  cartilaginous  tissue, 
which  much  resembles  gummatous  material,  to  be  discharged  externally. 

All  of  these  conditions  (except  the  last)  may  be  found  in  children  dead- 
born,  and,  any  of  them,  during  infantile  life,  with  or  without  other  evi- 
dences or  of  syphilitic  disease.  They  should  be  sought  for  in  the  foetus 
dead-born  and  prematurely  delivered,  if  there  be  any  reason  to  suspect 
syphilis  in  the  parents. 

Another  morbid  condition,  due  to  syphilis  and  described  by  Parrot, '  is 
the  formation  of  osteophytes  in  the  anterior  f ontanelle  of  the  growing  child, 
by  means  of  which  the  sutures  sometimes  become  ossified  and  the  develop- 
ment of  the  cranium  and  of  the  brain  interfered  with,  or  even  arrested. 

These  syphilitic  changes  in  the  ends  of  the  long  bones  may  require 
the  microscope  for  their  detection.  Often,  however,  the  changes  are 
manifest  to  the  unaided  eye.  The  thickening  at  the  end  of  the  bone  may 
be  felt  and  seen.  The  perforation  of  the  skin  and  gummatous  discharge 
can  be  seen  and  touched.  The  loss  of  function  is  obvious. 

It  is  possible  to  divide  the  minute  changes  into  three  degrees : 

In  the  first  degree  a  layer  of  osteophytic  growth  may  envelop  the  bone, 
sometimes  making  it  so  thick  as  to  double  its  diameter.  The  epiphyseal 
cartilage  is  also  thickened.  The  cartilage  cells  become  hypertrophied. 
Increased  proliferation  takes  place  within  them,  and  the  cartilage  becomes 
prematurely  infiltrated  with  earthy  salts. 

In  the  second  degree  there  is  premature  calcification  of  the  intercellu- 
lar substance  and  arrest  of  true  bony  formation. 

In  the  third  degree  there  is  softening,  and  inflammatory  changes  take 
place. 

The  exact  histological  nature  of  the  morbid  process  does  not  seem  to 

1  Ibid. 


INHERITED   SYPHILIS.  341 

be  invariably  the  same,  although  the  changes  always  take  place  in  a  line 
between  the  proliferating  and  the  hypertrophic  zone  of  the  cartilage,  as 
shown  by  Haab.1 

Wegner  looks  upon  the  process  as  an  osteochondritis  beginning  in 
the  cartilage.  He  believes  that  the  vascular  supply  through  the  vessels 
becomes  deficient,  through  a  too  rapid  deposit  of  bone  salts  on  the  one 
hand,  while  the  proliferating  cartilage  cells,  on  the  other  hand,  make  a 
stagnating  zone  between  the  proliferating  cartilage  and  the  medullary 
spaces  of  the  diaphysis. 

Others  have  pronounced  the  process  to  be  the  formation  of  a  syphilitic 
granulation  tissue,  growing  out  from  the  medullary  prolongations  of  the 
diaphysis  into  the  cartilage,  and  there  falling  into  softening  which  leads 
to  a  shedding  of  the  epiphysis. 

The  pathognomonic  value  of  these  changes  in  the  ends  of  the  long 
bones  is  very  great,  since  no  one  has  yet  claimed  to  have  found  them  pro- 
duced by  a  cause  other  than  syphilis,  and  they  may  therefore  be  largely 
instructive  as  to  the  cause  of  death  in  obscure  cases,  in  which  repeated 
miscarriages  take  place,  and  the  existence  of  syphilis  in  the  parents  is 
not  on  any  other  account  suspected. 

Periostitis  also  attacks  the  bones  of  syphilitic  children,  notably  the 
long  bones,  and  is  a  later  manifestation  than  the  previously  described 
condition,  generally  occurring  after  the  child  walks  about. 

Syphilitic  lesions  of  the  joints  assume  the  same  type  as  in  the  acquired 
form. 

Syphilitic  dactylitis  occurs  in  the  early  period  of  hereditary  syphilis, 
involving  swelling  'of  the  phalanges  and  metacarpal  bones,  sometimes 
invading  the  joints.  The  characters  of  these  lesions  resemble  those  of 
acquired  syphilis,  under  which  heading  they  are  described. 

The  treatment  of  syphilitic  children  upon  whom  these  lesions  exist  is 
very  effective.  It  should  be  a  mixed  treatment,  mercury  being  used  by 
inunction,  and  the  iodide  of  potassium  given  internally  in  repeated  doses 
well  diluted,  commencing  with  a  very  small  dose  (half  a  grain  or  less  for 
an  infant)  and  increasing  it  steadily  but  slowly,  as  it  is  tolerated,  until  a 
dose  producing  an  obvious  effect  is  reached.  A  dose  somewhat  smaller 
than  this  maximum  dose  may  be  continued  for  some  months  after  the  child 
has  recovered  from  all  local  evidences  of  progressive  disease. 

The  visceral  lesions  of  hereditary  syphilis  are  generally  more  severe 
than  in  the  acquired  disease. 

A  child  born  alive  with  inherited  syphilis3  may  have  its  lungs  so 

1  Virchow's  Archiv,  vol.  Ixv.  *Ibid.,  vol.  1. 

3  Acquired  syphilis  (for  example,  vaccinal  syphilis)  is  very  serious,  and  often 
rapidly  fatal  in  the  infant;  but  it  is  similar  to  acquired  syphilis  in  the  adult,  in 
that  the  visceral  lesions  only  come  on  after  a  longer  or  shorter  period  of  secondary 

eruptions. 


342  VENEREAL   DISEASES. 

stiffened  with  interstitial,  syphilitic,  cellular  changes  that  it  cannot 
breathe  sufficiently  to  support  life.  Its  liver  may  be  solid  with  parenchy- 
matous  changes,  and  it  may  grow  visibly  yellow  and  expire  in  a  few  days 
or  weeks,  without  any  especial  symptoms  on  the  skin  or  mucous  mem- 
branes. 

On  opening  the  abdomen  of  a  child  dead  with  inherited  syphilis,  an 
enormous  liver  is  often  found,  which  has  undergone  infiltrating  changes 
at  the  expense  of  the  normal  glandular  structure.  It  is  hard,  tense, 
elastic.  A  piece  of  it,  cut  out,  slips  away  when  pinched  between  the 
thumb  and  finger.  It  may  be  so  dense  that  the  finger  can  bore  a  hole 
in  it  only  with  difficulty.  Collapsed  and  thickened  vessels  show  on  the 
pinkish-brown  surface  of  section  as  white  knots,  from  which  radiate  thin 
whitish  streaks.  The  organ  is  the  seat  of  diffuse  interstitial  hepatitis. 

In  inherited  disease,  the  spleen  may  be  larger  and  harder  than  usual, 
but  gumrnata  are  rarely  found  in  it.  Eisenschutz1  thinks  that  enlarge- 
ment of  the  spleen,  easily  detected  by  palpation,  is  a  diagnostic  symptom 
of  latent  inherited  syphilis. 

Digestion  may  be  interfered  with  by  the  induration  of  the  pancreas, 
which  Birch- Hirschf eld2  found  to  be  so  common  in  his  autopsies  of  chil- 
dren dead  with  inherited  syphilis.  Occasionally  a  child  dies  in  convul- 
sions without  any  surface  signs  of  syphilis. 

Ordinarily,  however,  when  a  syphilitic  child  is  born  alive,  even  if  it 
happens  to  be  plump  and  fresh-looking  for  the  first  few  days,  very  char- 
acteristic changes  soon  begin  to  show  themselves.  The  face  grows  thin 
and  old-looking.  If  there  have  been  any  eruptive  phenomena  at  birth 
(excoriated,  papular,  scaly  patches),  these  increase  in  number  and  extent. 
If  the  skin  was  intact  at  birth,  it  begins  to  show  livid  patches,  which  run 
on  to  become  papular  or  pustular ;  or  excoriations  of  livid  color,  and  cracks 
and  fissures  appear,  with  pimples,  boils,  abscesses,  and  other  lesions. 
Condylomata  and  ulcers  at  the  anus  are  very  common.  The  skin  comes 
off  from  the  fingers  and  is  shed  from  the  palms  and  soles  in  large  patches ; 
sometimes  the  nails  come  off.  Mucous  patches,  fissures,  and  ulcers  ap- 
pear about  the  mouth.  In  fact,  the  child  with  hereditary  syphilis  is  sub- 
ject to  all  the  lesions  of  the  skin  and  mucous  membrane  which  appear  in 
the  acquired  form  (Fig.  105).  They  are  liable  to  be  more  diffuse  and  more 
severe.  Catarrh  involves  the  nostrils  and  the  child  gets  the  snuffles,  the 
nostril  caking  up  to  the  point  of  complete  obstruction,  so  that  the  child 
finds  it  difficult  or  impossible  to  nurse. 

Meantime  the  voice  grows  husky,  hoarse.  The  child  cries  in  a  fright- 
ened, explosive  way,  or  moans  its  life  out  in  croaking  sobs.  Dry,  tear- 
less, pitiful  crying  is  sometimes  the  method  the  poor  little  sufferer  takes 

'"Das  latente  Stadium  der  hereditaren  Syphilis,"  Wien.  med.  Wochenschrift, 
48,  49,  1873. 

2  Archiv  f.  Heilkunde,  February,  1875. 


INHERITED   SYPHILIS. 


to  announce  his  distress;  but  he  soon  becomes  marasmic,  and  death  cures 
him  of  his  pains. 

If  by  careful  nursing  and  active  treatment  he  pulls  through,  he  may 


FIG.  105.-lnherited  Syphilis.    Polymorphous  eruption.    (After  Kaposi,  Morrow.) 

become  marasmic  later,  or  be  stunted  in  his  growth,  perhaps  weakly  in 
constitution,  possibly  hydrocephalic.  During  his  early  life  he  may  have 
disease  in  his  bones,  ulcers,  gummata  in  different  positions,  ocular  trou- 


344  VENEREAL   DISEASES. 

bles ;  indeed,   he  is  exposed  to  a  long  series  of  disorders,  which,  if  not  • 
controlled  by  antisyphilitic  treatment,  make  life  a  burden  and  lead  to  de- 
struction of  tissue,  to  deformity,  to  loss  of  function  in  various  important 
organs. 

On  the  other  hand,  a  child  may  entirely  recover,  and,  after  a  reason- 
ably prolonged  treatment,  grow  up  to  good  health  and  become  as  vigorous 
as  any  one.  Such  children,  nevertheless,  may  have  syphilitic  teeth  and 
be  stamped  with  the  syphilitic  countenance  for  life. 

The  date  of  appearance  of  syphilitic  symptoms  upon  children  with 
inherited  disease,  who  are  born  apparently  in  perfect  health  (as  often 
happens),  is  very  variable.  Statistics  taken  in  lying-in  hospitals  make 
the  most  common  period  about  the  second  three  weeks  of  life.  .  Occasion- 
ally children  grow  up  to  be  several  months  old  before  symptoms  show 
themselves,  and  these  symptoms  may  be  quite  light  and  be  overlooked. 
Fournier  has  a  case  in  which  inherited  syphilis  appeared  at  the  age  of 
twenty-five;  Zambaco  has  one  at  twenty-six;  Bulkley  one  at  twenty- 
three,  and  another  at  twenty -four;  Dron  one  at  twenty. 

This  possibility  of  the  appearance  of  lesions  due  to  hereditary  syphilis 
late  in  life  must  be  constantly  kept  in  mind,  or  mistakes  are  quite  certain 
to  be  made,  to  the  grave  detriment  of  the  patient. 

The  following  are  important  external  manifestations  of  hereditary 
syphilis : 

Syphilitic  Pemphigus. — Flattened  bullae,  varying  in  size  from  that  of 
a  small  split-pea  to  that  of  a  penny,  situated  upon  a  red  base  with  a  red 
areola  and  containing  a  thin  sero-pus,  are  sometimes  found  scattered  over 
the  surface  of  syphilitic  children  at  their  birth,  or  coming  out  in  crops 
shortly  after  birth.  This  is  the  pemphigus  of  the  new-born;  it  is  nearly 
always  syphilitic  in  nature.  It  is  said  of  the  infantile  pemphigus  not 
syphilitic  that  it  always  first  attacks  other  parts  of  the  body,  appearing 
later  upon  the  palms  and  soles,  while  true  syphilitic  pemphigus  starts 
always  in  the  last-mentioned  localities,  and  may  indeed  remain  confined 
to  them.  The  bullae  burst  and  show  excoriated,  livid  surfaces  beneath, 
or  dry  up  into  greenish-yellow  crusts. 

Children  so  intensely  syphilitic  as  to  have  this  eruption  very  rarely 
recover  under  any  treatment.  Mercury  by  inunction  is  most  suitable. 

The  Syphilitic  Countenance. — Certain  physical  traits  of  countenance, 
marked  more  or  less  strongly  in  different  cases,  are  commonly  enough 
encountered,  upon  growing  children  with  inherited  syphilis,  to  be  consid- 
ered pathognomonic  of  the  disease.  They  constitute  what  Mr.  Hutchin- 
son  calls  the  syphilitic  countenance,  and  are  striking  enough  to  attract 
attention  and  to  put  an  observant  physician  upon  the  track  of  syphilis  in 
many  cases  before  he  has  asked  the  patient  a  single  question.  A  child 
with  inherited  syphilis  does  not  necessarily  have  the  syphilitic  counte- 
nance. Many  children,  unmistakably  syphilitic  by  inheritance,  bear  no 


INHERITED   SYPHILIS. 


345 


marks  that  distinguish  them  from  healthy  children.     One  child  in  a  fam- 
ily may  be  marked,  and  all  born  later  may  escape. 

In  a  child  somewhat  stunted  in  growth,  perhaps  looking  pinched  in  all 
its  physical  contour,  or  squared  and  dwarfed  in  stature,  generally  with  an 
abnormal  intelligence  running  to  precocity  which  delights  its  parents,  or 
to  a  stolid  stupidity  suggestive  of  idiocy 
— such  a  patient,  a  growing  boy  or 
girl,  without  any  positive  ulcers,  or 
nodes,  or  other  lesions  indicative  of 
syphilis,  will  be  found  often  to  have  a 
coarse  skin,  with  the  pores  more  marked 
than  usual.  His  color  will  not  be 
ruddy,  but  sallow,  dead-looking,  dry, 
or  perhaps  greasy.  His  face  will  look 
flattened  out,  rather  devoid  of  expres- 
sion, prematurely  old,  grave,  perhaps 
anxious.  His  forehead  is  rounded  and 
prominent,  like  that  of  a  hydrocephalic 
child.  The  eyes  are  often  small,  the 
nose  is  undeveloped,  particularly  at  the 
bridge,  which  remains  broad  and  sunken 
as  it  was  in  babyhood.  The  corners  of 
the  mouth  are  often  puckered  with  ci- 
catrices, representing  old  ulcers  at  the 
angles ;  other  scars  may  mark  the  mu- 
cous membrane  lining  the  cheeks,  and 
the  throat  may  exhibit  the  ravages  of 
past  ulceration.  Such  a  child  is  apt 
to  have  constant  chronic  nasal  and 
pharyngeal  catarrh.  With  this  physi- 
ognomy the  syphilitic  teeth  are  apt  to  F:G- 106- 
be  found,  and  marks  of  old  iritis,  choroiditis,  or  interstitial  keratitis, 
and  more  or  less  deafness,  are  rather  the  rule  than  the  exception. 

Fig.  106  represents  very  fairly  the  syphilitic  countenance,  together 
with  scars  of  ulcers,  nodes,  overgrown  and  irregular  bones,  and  the  general 
ungainly  shape  of  a  girl  who  has  suffered  severely  from  inherited  syphilis. 

Syphilitic  and  Mercurial  Teeth. — Hutchinson,  in  his  "  Illustrations  of 
Clinical  Surgery,"  London,  1876,  has  described  and  figured,  with  copious 
illustrations,  the  effects  of  syphilis  in  modifying  the  shape  of  the  central 
incisors  of  the  upper  jaw,  as  well  as  the  changes  in  the  teeth  produced 
by  the  use  of  mercury  during  their  forming  stage.  Mercurial  teeth  are 
very  often  found  in  the  mouth  along  with  syphilitic  teeth,  and  the  mer- 
curial teeth  were  generally  considered  to  be  also  syphilitic  until  Hutch- 
inson clearly  pointed  out  the  distinction  between  them. 


346 


VENEREAL   DISEASES. 


The  true  syphilitic  "  test  teeth, "  as  Hutchinson  calls  them,  are  the 
two  central  incisors  in  the  upper  jaw,  the  teeth  of  the  permanent  set. 
The  milk  teeth  do  not  show  this  typical  peculiarity  of  structure,  and  no 
other  teeth  can  be  relied  upon  to  indicate  the  presence  of  hereditary  syph- 
ilis, excepting  the  two  above  mentioned.  The  first  set  of  teeth  may  be 
chalky,  and  fall  into  rapid  caries;  the  second  set  may  also  be  very  defect- 
ive, falling  rapidly  into  caries,  some  of  them  stunted  in  growth,  some  of 
them  placed  crosswise  or  altogether  out  of  place  in  the  mouth ;  but  none 
of  these  peculiarities  are  essentially  syphilitic.  On  the  other  hand,  a 

child  may  be  markedly  syphilitic 
by  inheritance,  and  yet  its  teeth  be 
perfectly  sound. 

The  "  test  teeth  "  are  found  only 
in  connection  with  inherited  syphi- 
lis.    The  two  central  incisors  are 
smaller  than  natural,  and  usually 
FIG.  107.  ,      converge  somewhat   (Fig.  107),  or 

diverge  a  little.  The  cutting  bor- 
der is  narrower  than  the  base  of  the  tooth,  making  it  peg-shaped,  and 
along  the  lower  edge  uniformly  indented  with  a  single  broad  notch,  as 
shown  in  the  plate. 

These  single  broad  notches  are  the  features  of  the  teeth  which  stamp 
them  as  syphilitic.  The  serrations  at  the  cutting  border  of  the  incisor 
teeth,  produced  by  a  number  of  shallow  notches,  mean  nothing  so  far 
as  syphilis  is  concerned.  They  are  seen  not  infrequently  upon  all  the 
incisors,  of  the  lower  jaw  particularly.  Irregular  notches,  even  in  the 
centre  of  the  upper  central  permanent  incisors,  are  not  pathognomonic ; 
and  peg-shaped  teeth,  or  teeth  uneven  in  any  respect,  or  badly  placed  or 
seamed  or  discolored,  have  no  value  as  indicating  antecedent  syphilis. 
The  "  test  teeth, "  as  above  described,  are  caused  by  syphilis,  and  are  not 
caused  by  anything  else  so  far  as  has  yet  been  discovered. 

Generally,  when  the  edge  of  the  notched  tooth  is  thin,  it  chips  off,  and 
wears  down  with  advancing  life,  and  finally  loses  its  characteristic  appear- 
ance. 

Mercurial  teeth  illustrate  the  effect  of  the  excessive  use  of  mercury — of 
mercurial  stomatitis  upon  the  permanent  teeth.  The  teeth  most  plainly 
marked  by  mercurial  stomatitis  are  the  first  (the  anterior)  molars.  The 
incisors  and  the  canine  teeth  suffer.  The  bicuspids  escape.  The  mer- 
curial tooth  is  deficient  in  enamel,  covered  with  ridges  and  spines  of 
exposed  dentin,  dirty-looking,  and  apt  to  become  promptly  carious. 
Quite  often  only  the  half  of  the  tooth  farthest  removed  from  the  gum  is 
unhealthy,  the  half  nearest  the  gum  preserving  its  enamel  in  a  smooth 
and  reasonably  white  condition.  The  grinding  surface  of  the  molars  is 
involved  in  the  affection.  Very  naturally  the  influence  of  mercury  is  also 


INHEKITED    SYPHILIS.  347 

often  shown  upon  the  typical  syphilitic  teeth,  but  this  is  accidental,  and 
by  no  means  essential. 

Hutchinson  states  that  other  forms  of  stomatitis  may  also  produce  this 
change  upon  the  permanent  teeth,  but  it  is  more  marked  and  more  com- 
mon after  mercurial  stomatitis. 

Interstitial  Keratitis. — The  cornea  is  frequently  the  seat  of  a  chronic 
interstitial  inflammation  in  cases  of  inherited  syphilis.  The  affection  is 
most  common  between  the  ages  of  six  months  and  three  years,  most  com- 
mon of  all  during  second  dentition,  but  may  be  observed  during  adoles- 
cence. Occasionally  it  is  encountered  in  acquired  syphilis. 

The  affection  comes  on  insidiously,  with  slight  peripheral  cloudiness 
of  the  cornea  advancing  toward  its  centre,  attended  by  moderate  photo- 
phobia and  more  or  less  of  a  pericorneal  zone  of  subconjunctival  hyper- 
semia.  Sometimes  the  symptoms  become  quite  intense.  The  cornea  grad- 
ually grows  quite  white,  and  sight  may  become  so  reduced  that  only  the 
difference  between  light  and  darkness  can  be  perceived.  The  cornea  may 
become  soft  and  fluctuating  in  spots  by  diffuse  infiltration  of  pus.  Ulcera- 
tion  is  uncommon,  or  very  superficial  if  it  occurs. 

Gradually,  as  the  malady  gets  well,  the  whiteness  disappears  from 
the  periphery  toward  the  centre,  leaving  sometimes  clouded  spots  behind. 
The  iris,  the  choroid,  and  the  ciliary  body  may  be  involved  in  inflamma- 
tion during  the  course  of  the  disease. 

Both  eyes  may  be  involved  consecutively.  The  affection  in  each  eye 
lasts  from  a  few  months  to  more  than  a  year.  Kelapse  is  possible. 

Treatment. — Hygiene  and  dietetics  form  an  essential  part  of  the  treat- 
ment in  these  cases.  Cod-liver  oil,  tonics,  and  change  of  air  are  of  great 
service.  Treatment  by  mercurial  inunction  is  of  the  most  value,  or  mild 
internal  mercurial  preparation  may  be  used,  due  attention  being  paid  to 
the  digestion.  The  course  must  be  persevered  in  persistently,  with  con- 
fidence of  ultimate  success  in  preserving  vision,  if  the  general  health  re- 
mains good. 

Local  treatment  is  of  some  assistance,  but  not  so  valuable  as  the  gen- 
eral measures.  Warm  fomentations  in  the  beginning  of  the  affection  are 
recommended,  and  instillations  of  a  solution  of  atropine  are  of  consider- 
able advantage,  especially  in  those  cases  in  which  the  iris  is  threatened  or 
involved  in  inflammation. 

In  inherited  syphilis  the  ear  suffers  in  two  ways.  There  may  arise, 
in  a  child  with  inherited  syphilis,  a  catarrhal  condition  of  the  middle  ear 
which  is  very  obstinate,  and  likely  to  result  in  inflammatory  adhesions  of 
the  ossicula  and  permanent  impairment  of  hearing. 

Internal  mercurial  treatment,  with  cod-liver  oil,  and  plenty  of  suit- 
able food,  constitute  the  best  measures  to  be  employed  against  this  affec- 
tion, in  combination  with  change  of  air,  syringing  of  the  external  and 
inflation  of  the  internal  ear. 


348  VENEREAL   DISEASES. 

Deaf-mutism  sometimes  occurs  in  children  with  inherited  syphilis  who 
have  been  born  with  perfect  capacity  for  hearing.  Jonathan  Hutchinson 
has  called  attention  to  a  loss  of  hearing  which  may  come  on  very  suddenly, 
sometimes  quite  slowly,  in  children  with  inherited  disease,  after  they  have 
begun  to  talk,  but  before  the  age  of  puberty.  This  affection  is  apparently 
an  essentially  nervous  maladj ,  not  attended  by  any  pain.  There  is  no 
evidence  to  prove  that  the  lesion  is  inflammatory.  Treatment  is  of  little 
or  no  value  in  these  cases,  and  their  pathology  is  not  understood. 

TREATMENT  OF  INHERITED  SYPHILIS. 

In  the  chapter  upon  the  general  treatment  of  syphilis,  great  stress 
was  laid  upon  the  fact  that  mercury  was  a  natural  antidote  to  syphilis, 
more  or  less  useful  in  all  its  stages,  most  valuable  in  its  power  of  keeping 
the  disease  in  check,  and  very  certainly  possessed  of  ability  gradually  to 
eliminate  the  disease  and  retard  relapses  of  symptoms.  In.  tertiary  forms 
of  syphilis,  however,  mercury  was  accorded  only  a  second  rank  among 
remedies,  the  preparations  of  iodine,  notably  the  different  iodides,  taking 
the  lead. 

In  inherited  syphilis  all  the  stages  of  the  disease  come  together,  as  it 
were.  The  child  is  born  already  permeated  through  and  through  with 
syphilis,  and  possessing  at  the  same  time  visceral  and  bony  changes  due 
to  tertiary  alterations  of  tissue  and  secondary  phenomena,  in  the  shape 
of  excoriations,  papules,  pustules.  The  discharges  from  many  of  these 
lesions  are  essentially  and  actively  contagious.  « 

In  inherited  disease,  notwithstanding  these  pathological  facts,  the 
iodides  can  usually  be  dispensed  with,  except  when  dealing  with  the  late 
lesions  of  adolescence  and  bone  lesions  occurring  during  childhood.  Com- 
monly, all  the  good  that  can  be  obtained  from  treatment  may  be  derived 
from  a  persistent  use  of  mercury,  not  pushed  to  the  extent  of  producing 
salivation. 

Salivation  is  very  difficult  to  produce  in  young  infants.  Excess  of 
mercury  given  to  them  generally  runs  itself  off  by  the  bowels.  Just  be- 
fore, and  during  the  period  of  second  dentition,  especial  care  is  necessary 
in  the  use  of  mercury,  in  order  to  avoid  causing  enough  stomatitis  to  give 
rise  to  mercurial  teeth. 

Mercury  is  introduced  into  the  circulation  of  syphilitic  children  pref- 
erably through  the  skin.  The  only  obstacle  to  this  is  extensive  ulceration 
of  the  surface  (and  even  this  does  not  preclude  the  possibility  of  dusting 
the  skin  with  calomel),  or  the  existence  of  so  great  an  irritability  of  the 
integument,  that  the  local  use  of  mercury  cannot  be  borne.  This,  how- 
ever, is  exceptionally  uncommon.  The  advantage  of  administering  mer- 
cury by  the  skin  is  that  it  spares  the  child's  stomach  for  food.  At  no 
period  of  life  is  it  so  essential  that  the  stomach  should  be  unhindered  in 


INHERITED   SYPHILIS.  349 

the  performance  of  its  function  as  during  babyhood.  Another  excellent 
reason  for  employing  inunction  upon  babies  is,  that  it  is  often  impossible 
to  say  whether  they  get  enough  mercury  if  the  stomach  is  relied  upon, 
and  valuable  time  may  be  lost  in  this  uncertainty.  Some  babies  vomit 
more  or  less  after  each  feeding,  and  are  constantly  regurgitating  between 
their  repasts,  and  whether  all  of  a  powder  or  potion  given  internally  stays 
down  or  not  is  sometimes  a  matter  of  great  uncertainty. 

If  inunction  is  decided  upon,  twenty  grains  of  mercurial  ointment  may 
be  rubbed  daily  into  a  different  part  of  the  child's  integument,  the  dose 
being  regulated  by  the  intensity  of  the  symptoms  and  the  age  and  vigor 
of  the  child.  A  better  plan  than  this,  although  it  is  dirtier,  is  to  spread 
upon  the  flannel  belly-band  of  the  child  a  thick  patch  of  blue  mercurial 
ointment,  and  bind  it  against  the  integument,  removing  it  daily,  and 
washing  the  skin  well  with  warm  water  and  soap. 

If  any  eruption  or  mercurial  erythema  appears  at  the  site  of  the  mer- 
curial application,  a  new  spot  should  be  selected,  and  the  irritated  skin 
washed  with  a  delicate  toilet  soap  and  abundantly  powdered,  while  a 
piece  of  old  linen  should  be  worn  under  the  binder,  between  it  and  the 
impending  mercurial  eruption.  While  the  belly  is  recovering,  the  legs, 
thighs,  feet,  and  arms  may  be  used  for  inunction  or  for  the  continued 
application  of  ointment  upon  bandages. 

By  this  too  much  mercury  can  hardly  be  used.  As  soon  as  the  snuffles, 
the  eruptive  lesions,  and  the  restlessness  of  the  child  begin  to  mend  per- 
ceptibly, the  quantity  of  inunction  or  of  the  ointment  bound  upon  the 
surface  may  be  diminished ;  but  the  treatment  must  be  kept  up  steadily 
in  a  mild  way  in  some  form  or  Bother,  certainly  as  long  as  through  the 
period  of  the  second  dentition. 

If  for  any  other  reason  it  is  deemed  advisable  to  use  mercury  internally 
instead  of  by  inunction,  the  gray  powder,  mercury  with  chalk,  is  a  prepa- 
ration sanctioned  by  long  usage.  This  may  be  administered  in  powder, 
commencing  with  one-sixth  to  one-quarter  of  a  grain  two  or  three  times  a 
day,  and  working  up  the  dose  rapidly  or  slowly  according  to  the  intensity 
of  the  symptoms,  until  the  latter  show  signs  of  yielding  or  the  bowels 
are  irritated  by  the  drug. 

In  the  latter  case  it  is  better  to  diminish  the  dose  or  to  substitute 
inunction,  or,  in  some  cases,  when  a  continuance  of  a  large  dose  is  very 
desirable,  the  bowels  may  be  quieted  by  the  internal  use  of  mild  doses  of 
opium.  This,  however,  will  very  rarely  be  called  for. 

A  good  way  of  producing  a  rapid  effect  of  mercury  upon  a  child  is  to 
dissolve  a  half  grain  of  corrosive  sublimate  in  six  ounces  of  water,  and  to 
give  a  teaspoonful  of  this  hourly  for  the  first  day,  then  every  two  hours, 
finally  every  three  hours  or  at  longer  intervals,  unless  it  obviously  dis- 
agrees. 

This  watery  solution  has  absolutely  no  taste.     The  child  who  will  spit 


350  VENEREAL  DISEASES. 

out  a  powder  will  take  this  solution,  believing  it  to  be  water.  The  medi- 
cine will  mix  with  milk  without  turning  it,  or  with  any  food  in  such  a 
way  that  its  presence  is  unsuspected ;  and  if  the  whole  or  a  portion  of  a 
given  dose  should  be  regurgitated  by  an  infant,  it  is  not  a  very  serious 
matter,  since  the  doses  follow  each  other  in  such  quick  succession. 

The  average  interval  between  the  doses  should  be  three  to  four  hours 
for  prolonged  treatment,  the  intervals  being  shortened  when  a  prompt  or 
vigorous  mercurial  influence  is  desired.  Mercurial  stomatitis  is  not 
likely  to  occur  with  the  use  of  this  remedy  in  this  way,  and  intestinal  dis- 
turbance is  equally  uncommon — plenty  of  warning  being  given  by  premon- 
itory symptoms  before  any  explosion  comes  on,  so  that  there  is  time  to 
avert  the  latter. 

Iodide  of  potassium  may  be  administered  through  the  milk  of  the 
mother,  or  in  mild  doses  by  the  mouth  of  the  infant,  provided  the  dose 
be  given  with  the  food  and  be  itself  considerably  diluted  with  water. 

In  no  case  should  a  child  born  of  syphilitic  parents,  whether  it  shows 
evidences  of  inherited  disease  or  not,  be  allowed  to  suckle  a  healthy  wet- 
nurse.  The  risk  of  infecting  the  latter  is  too  great  to  be  overlooked.  A 
syphilitic  child  may,  however,  suckle  its  mother  with  advantage,  and  can 
never  infect  her  (Colles's  law),  even  although  she  be  considered  healthy 
and  has  never  shown  any  symptom  of  syphilis.  The  same  rule  applies  to 
a  wet-nurse.  A  syphilitic  woman  may  have  recovered  and  may  secrete 
good  milk,  and  such  milk  is  perfectly  suitable  for  the  child,  while  the 
latter  cannot  poison  the  nurse. 


INDEX. 


ABDOMINAL   lymphatic  glands,   syphilis 

of,  310 

Abortion,  syphilitic,  336 
Abortive  treatment  of  gonorrhoea,  26 
Abscess  in  epididymitis,  99 
of'Cowper's  glands,  71 
of  follicles  of  urethra,  68 
of  prostate,  73 
periprostatic,  73,  75 
Alopecia,  syphilitic,  288 

treatment,  289 
Antiphlogistic  method  of  treating  gonor- 

rhrea,  25 

Anus,  chancre  of,  214 
Argonin  in  acute  urethritis,  33,  34 
Arteries,  syphilis  of,  202,  311 
Arteritis,    primary    syphilitic,    of    the 

brain,  318 
diagnosis  of,  319 
symptoms  of,  319 
Aspiration  of  bladder  for  impermeable 

stricture,  151 
Astringent  injections,  26 
Atrophy  of  testicle  after  epididymitis,  99 
Auditory  nerve,  syphilis  of,  334 
Auto-inoculation  of  chancroid,  172 
Azoospermia  as  a  sequel  to  epididymitis, 
100 

BACTERIA  of  non-specific  urethritis,  8 

Bacteruria,  95 

Balanitis  and  posthitis,  54 

complications  of,  54 

diagnosis  and  treatment,  55 
Basal  meningitis,  syphilitic,  315 
Bladder,  aspiration  of,  151 
Bone,  gumma  of,  299 
Bones,  syphilis  of,  297 
Brain,  syphilis  of,  315 
Bronchi,  syphilis  of,  304 
Bubo,  chancroidal,  193 
cause  of,  192 

indolent,  195 

simple,  194 


Bubo,  simple,  symptoms  of,  194 

treatment  of,  196 
syphilitic,  217 
virulent,  195 

treatment  of,  196 
Bursae,  syphilis  of,  293 

CARTILAGE,  syphilis  of,  301 
Cerebral  syphilis,  315  (see  Syphilis) 
Chancre,  course  of,  214 

excision  of,  213 

herpetiform,  212 

Hunteriau,  212 

induration  of,  214 

mixed,  212 

of  anus,  214 

of  fingers,  213 

of  general  integument,  212 

of  lip,  213 

of  nipple,  213 

of  tongue,  213 

of  tonsil,  213 

of  urethra,  213 

phagedsena  of,  213 

treatment  of,  218 

varieties  of,  211 
Chancroid,  167 

auto-inoculation  of,  171 

clinical  history  of,  174 

complications  of,  186 

definition  of,  167 

description  of,  167 

diagnosis  of,  177 

duration  of,  176 

etiology  of,  169 

follicular,  168 

inoculability,  171 

manner  of  contagion,  173 

pathological  histology,  169 

phagedenic,  187 

gangrenous,  188 
serpiginous,  186 
treatment,  189 

situation,  175 


352 


INDEX. 


Chaucroid,  treatment,  179 

varieties,  168 

Chancroids,  anal  and  rectal,  184 
of  fingers,  185 
of  margin  of  prepuce,  184 
Changes  in  the  cornea  due  to  syphilis, 

330 

Chetwood's  method  of  irrigating  the  ure- 
thra, 30 

Choc  en-retour,  206 
Chordee,  15 

treatment  of,  24 
Circumcision,  62 
Cock's  operation,  152 
Condylomata  (see  Venereal  warts) 

lata,  268 

Congenital  stricture,  107,  115 
Constitutional  syphilis,  220  (see  Syphilis) 
Continuous  dilatation  in  the  treatment  of 

stricture,  131 

Contracture  of  the  neck  of  the  bladder,  88 
Copaiba,  balsam  of,  in  urethritis,  22 
Copaibal  erythema,  23 
Copper  sulphate  in   chronic  urethritis, 

48 

Cortical  meningitis,  syphilitic,  319 
Cowper's  glands,  abscess  of,  71 
inflammation  of,  70 
symptoms,  71 
treatment,  72 
Cowperitis,  70 
Cubebs  in  urethritis,  23 
Cystitis,  gonorrhoeal,  acute  and  chronic, 

89 

symptoms,  91 
treatment,  internal,  92 
local,  94 

DACTYLITIS,  295 

diagnosis,  297 
treatment,  297 

Digestive  tract,  syphilis  of,  305 
Dilatation,  continuous,  in  the  treatment 

of  stricture,  131 

progressive,  in  the  treatment  of  stric- 
ture, 126 
rapid,  in  the  treatment  of  stricture, 

134 

Divulsion,  treatment  of  stricture  by,  143 
Dressings  of  the  penis  in  urethritis,  34, 
35 

EAR,  syphilis  of,  334 


Electrolysis,  125 

Endoscope,  topical  applications  by  means 

of,  51 
Endoscopic  examination  of  the  urethra, 

26,  139 
Epididymitis,  chronic  relapsing,  104 

operation  for,  104 
gonorrhoeal,  96 

complications  and  sequelae,  99 
symptoms,  97 
treatment,  101 

Erythematous   patches  of  mucous  mem- 
branes, syphilitic,  284 
syphilide,  264 
Excision  of  chancre,  218 
External  perineal  urethrotomy,  145  (see 

Perineal  section) 
Extravasation  of  urine,  152 
symptoms  of,  153 
treatment  of,  153 

Eye,  non-specific  affections  and  gonor- 
rhoeal rheumatism,  159 
treatment,  160 
syphilis  of,  330 

FEMALE  pelvic  organs,  syphilis  of,  328 

Fingers,  chancre  of,  213 

Follicles  of  urethra,  inflammation  of,  78 

treatment,  69 
Follicular  abscess  of  the  urethra,  68 

prostatitis,  72 

Fumigations,  mercurial,  242  (see  Syphi- 
lis) 

GENERAL  paresis  and  syphilis,  320 
Gonococcus  of  Neisser,  7,  9,  10 

cultivation  of,  7,  9 

Gram  test  for,  9,  11 

identification  of,  10 

pseudo-,  7 

staining  of,  11 
Gonorrhoea,   abortive    treatment    of,  26 

(see  Urethritis) 
Gonorrhoeal  ophthalmia,  160 

diagnosis  and  prognosis  of,  161 

symptoms  of,  161 

treatment  of,  162 
rheumatism,  157 

diagnosis,  158 

symptoms  of,  157 

prognosis  of,  158 

treatment  of,  158 


INDEX. 


353 


Gram's  method  of  staining,  9,  11 

solution,  11 
Gumma  of  bone,  299 

of  iris,  331 

of  skin,  282 

of  tongue,  305 
Gummatous  ulcers  of  mouth  and  fauces, 

286 
Gummata  of  brain,  320 

of  lungs,  305 

HAIR,  syphilis  of,  288 
Heart,  syphilis  of,  310 
Herpes  progenitalis,  56 

diagnosis  and  treatment,  57 
Herpetiform  chancre,  212 
Hot  Springs  of  Arkansas,  226 
Hunterian  chancre,  212 
Hydrocele,  chronic,  after  -epididymitis, 

100 
Hypodermatic  treatment  of  syphilis,  244 

(see  Syphilis) 

INCUBATION  period  of  syphilis,  211 
Induration  of  chancre,  214 
Inflammatory  phimosis,  59 

stricture,  107 
Inherited  syphilis,  336 

symptomatology  of,  339 
treatment  of,  348 
Inoculability  of  chancroid,  171 
Instillations  in  chronic  prostatitis,  84 

in  chronic  urethritis,  45 
Integument,  chancre  of,  212 
Internal  urethrotomy,  134 
Intestines,  syphilis  of,  307 
Inunctions,  mercurial,  239  (see  Syphilis) 
Iodide  preparations  in  treatment  of  syph- 
ilis, 251  (see  Syphilis) 
lodism,  253 
Iris,  gumma  of,  331 

Irrigation  treatment  of  urethritis,  29,  45 
Irrigations,  rectal,  in  chronic  prostatitis 
and  vesiculitis,  85,  88 

urethral  and  intravesical,  28 

JANET'S  method  of  irrigation,  28 
Joints,  syphilis  of,  294 

KERATITIS,      interstitial,     in    inherited 

syphilis,  347 

Keyes'  tonic  treatment  of  syphilis,  235 
Kidney,  syphilis  of,  324 
23 


LARYNX,  syphilis  of,  302 
Ligation  of  vas  deferens  for  chronic  re- 
lapsing epididymitis,  106 
Lip,  chancre  of,  213 
Liver,  syphilis  of,  309 
Local   treatment  of  chronic  urethritis, 
43 

treatment  of  acute  specific  and  non- 
specific urethritis,  25 
Locomotor  ataxia  and  syphilis,  322 
Lungs,  gummata  of,  305 

syphilis  of,  304 
Lymphangitis,  chancroidal,  186,  192 

syphilitic,  217 
Lymphatic  glands,  syphilis  of,  287 

MACULAR  syphilide,  264 
Male  genitals,  syphilis  of,  325 
Meatus,  method  of  cutting,  134 
Meningitis,  basal,  syphilitic,  315 

affections  of  cranial  nerves  in, 

316 

arterial  symptoms  in,  318 
course  of,  317 

peduncular  symptoms  in,  317 
cortical  syphilitic,  319 
Mercurial  fumigation  in    treatment   of 

syphilis,  239 
inunctions  in  treatment  of  syphilis, 

242 

teeth,  346 
Micro-organisms  of  the  anterior  urethra, 

7 

resembling  the  gonococcus,  8 
Mixed  chancre,  212 

treatment  for  syphilis,  257 
Mouth  and  fauces,  gummatous  ulcers  of, 

286 
Mucous    membranes,    syphilis    of    (see 

Syphilis) 
patches,  284 
Muscles,  syphilis  of,  292 

NAILS,  syphilis  of,  289 

Neisser,  gonococcus  of,  7,  9 

Nervous  system,  syphilis  of,  312 

Neuralgia  of  testicle  after  epididymitis, 
100 

Nipple,  chancre  of,  213 

Non-specific  affections  of  the  eye  com- 
plicating urethral  inflammation,  159 

Nose,  syphilis  of,  302 


354 


INDEX. 


(ESOPHAGUS,  syphilis  of,  307 

Onychia,  syphilitic,  289  (see  Syphilis  of 

the  nails) 
treatment,  290 
Ophthalmia,  gonorrhoeal  (see  Gonorrhoeal 

ophthalmia) 

Optic  neuritis,  syphilitic,  333 
Organic  stricture,  107 
Osteocopic  pains,  297 
Osteoperiostitis,  syphilitic,  298 

PAPULAR  syphilide,  265 
Papulo-squamous  syphilide,  267,  272 
Paraph  imosis,  60 

treatment  of,  61 
Parenchymatous  prostatitis,  73 
Pericowperitis,  70 
Perineal  section  with  a  guide,  146 

without  a  guide,  150 
Periurethral  inflammation,  69,  71 
Permanganate  of  potassium  irrigations, 

32,  43,  45 

Phagedsena  of  chancre,  213 
Phimosis,  chancroidal,  186 
complicating  balanitis,  66 
inflammatory,  59 
Pigmentary  syphilide,  271 
Posthitis  (see  Balanoposthitis) 
Progressive  dilatation  in  the  treatment  of 

stricture,  125 
Prostate,  abscess  of,  73 
Prostatitis,  acute,  72 

diagnosis  of,  75 

follicular,  72 

parenchymatous,  73 

symptoms  and  course  of,  74 

treatment  of,  76 
chronic,  77 

diagnosis  of,  80 

symptoms  of,  78 

treatment  of,  83 
Prostatorrhcea,  77,  79 
Protargol  in  acute  urethritis,  33,  34 

in  chronic  urethritis,  49 
Pustular  syphilide,  269 
Pustulo-bulbous  syphilide,  277 

RAW  erosion  (chancre),  211 

Rectum,     gummatous     infiltration     of, 

308 

Reinfection,  syphilitic,  208 
Respiratory  system,  syphilis  of,  302 


Retrograde  catheterism  during  perineal 

section,  152 
Rheumatism,  gonorrhoeal  (see  Gonorrhceal 

rheumatism) 

Roseola,  264  (see  Ery  thematous  syphilide) 
Rupial  syphilide,  277 

SALIVATION,  245 

Sandal  wood,  oil  of,  in  urethritis,  21 
Sclerosis  of  tongue,  syphilitic,  305 
Seminal  vesicles,  inflammation  of,  86 
vesiculitis,  acute  and  chronic,  86 
Silver  compounds,  topical  use  of,  in  acute 

urethritis,  32 
instillations  of,  in  chronic  urethritis, 

45,  49 

Skin,  gumma  of,  282 
syphilis  of,  261 

Spasm,  urethral,  107  (see  Stricture) 
Spasmodic  stricture,  107  (see  Stricture) 
Specific  treatment  of  syphilis,  232 
Spermatocystitis  (see  Seminal  vesiculi- 
tis) 

Spermatorrhoea,  82 
Spinal  syphilis,  320 
Spleen,  syphilis  of,  310 
Stages  of  syphilis  (see  Syphilis) 
Sterility  after  epididymitis,  100 
Stomach,  syphilis  of,  307 
Stricture  of  the  urethra,  107 
acquired,  107 
annular,  113 
congenital,  107,  115 
fibrous,  113 
inflammatory,  107 
inodular,  113 
large  calibre,  114 

diagnosis,  120,  122 
linear,  113 
organic,  107,  110 
etiology,  110 
diagnosis,  118 
location  of,  111 
symptoms,  116 
treatment,  120 
resilient,  127 
small  calibre,  114 
diagnosis,  122 
soft,  113 
spasmodic,  107 
time  of  development  of,  111 
traumatic,  107,  116 


INDEX. 


355 


Stricture,  traumatic,  treatment,  110 
Superficial  ulceration  (chancre),  212 
Suprarenal  capsules,  syphilis  of,  310 
Swelled  testicle  (see  Epididymitis) 
Syphilide,  erythematous,  264 
macular,  264 
palmar  and  plantar,  274 
papular,  265 

papulo-squamous,  267,  272 
pigmentary,  271 
pustular,  269 

tertiary,  279 
pustulo-bulbous,  277 
rupial,  277 

superficial  ecthymatous,  270 
tubercular,  275 
vesicular,  271 
Syphilides,  263 

absence  of  subjective  symptoms  with, 

262 

cicatrices  of,  263 
color  of,  262 

form  and  distribution  of,  262 
polymorphism  of,  261 
scabs  and  ulcers  of,  263 
tertiary,  277 
Syphilis,  198 

and  pregnancy,  336 
cerebral,  315 
constitutional,  220 
course  of,  199 
definition  of,  198 
general  pathology  of,  201 
general  treatment,  224 

hygienic,  227 
incubation,  211 
inherited,  336 

symptoms  of,  239 
treatment  of,  348 
local  treatment,  247 
methods  of  contagion,  203,  207 
of  the  arteries,  202,  311 
of  the  bones,  297 
of  the  bronchi,  304 
of  the  bursse,  293 
of  the  cartilage.  301 
of  the  digestive  tract,  305 
of  the  ear,  334 
of  the  eye,  330 

of  the  female  pelvic  organs,  328 
of  the  hair  and  nails,  288 
of  the  heart,  310 


Syphilis  of  the  intestines,  307 
of  the  joints,  294 
of  the  kidney,  324 
of  the  larynx,  302 

non-ulcerative  laryngitis,  303 

ulcerative  laryngitis,  303 
of  the  liver,  309 

diffuse  syphilitic  hepatitis,  309 

gummatous  hepatitis,  309 
of  the  lungs,  304 
of  the  lymphatic  glands,  287 
of  the  male  genitals,  325 
of  the  mucous  membranes,  249,  284 

erythematous  patches,  erosions, 
284 

mucous  patches,  284 

mucous  patches,  treatment,  250 

scaly  patches,  285 
of  the  muscles,  292 
of  the  nervous  system,  312 

causation,  312 

pathology,  312 

prognosis,  322 

treatment,  323 
of  the  nose,  302 
of  the  oesophagus,  307 
of  the  pancreas,  309 
of  the  peritoneum,  309 
of  the  rectum,  307 

chronic  hyperplastic  infiltration, 
308 

gummatous  infiltration,  308 

ulcerations,  308 
of  the  respiratory  system,  302 
of  the  skin,  261 
of  the  spleen,  310 
of  the  stomach,  307 
of  the  tendons  and  aponeuroses,  293 
of  the  testicle,  326 
of  the  thyinus,  suprarenal  capsules, 
and  abdominal  lymphatic  glands, 
310 

of  the  tongue,  305 
of  the  trachea,  304 
of  the  vascular  system,  310 
of  the  viscera,  302 
primary  lesion,  211  (see  Chancre) 
prognosis  of,  208 
spinal,  320 
stages  of,  220 

symptoms  attending  the  general  out- 
break of,  222 


356 


INDEX. 


Syphilis,  transmission  of,  203 

to  third  generation,  207 
treatment,  general,  224 

hygienic,  227 

hypodermatic,  244 

iodide  preparations,  251 

local,  247 

mercurial  fumigations,  242 

mercurial  inunctions,  239 

mixed,  257 

specific,  232 

tonic,  235 

Syphilitic  alopecia,  288 
bubo,  217 

duration  of,  218 

treatment  of,  218 

countenance  in  inherited  disease,  344 
node,  298 
optic  neuritis,  333 
pemphigus  in  inherited  disease,  344 
poison,  secretions  which  contain,  203 
reinfection,  208 
roseola,  264 
teeth,  345 
tertiary  ulcer,  281 

TEETH,  mercurial,  346 

syphilitic,  345 
Tendons  and  aponeuroses,  syphilis  of, 

293 
Tertiary  pustular  syphilide,  279 

syphilides,  277 

ulcer,  syphilitic,  281 
Testicle,  abscess  of,  with  epididymitis, 
99 

atrophy  of,  after  epididymitis,  99 

neuralgia  of,  after  epididymitis,  100 

syphilis  of,  326 
Thallin  sulphate   in  chronic  urethritis, 

47 

Thymus,  syphilis  of,  310 
Tongue,  chancre  of,  213 

gumma  of,  305 

sclerosis  of,  305 

syphilis  of,  305 

Tonic  treatment  of  syphilis,  235 
Tonsil,  chancre  of,  213 
Trachea,  syphilis  of,  304 
Transmission  of  syphilis,  203 
Traumatic  stricture  of  urethra,  107,  116 
Tubercular  syphilide,  275 
Turpentine  in  urethritis,  24 


ULCERATION,  chancroidal,  168 
chancrous,  212 
tertiary  syphilitic,  281 
Urethra,  chancre  of,  213 

endoscopic  examination  of,  26,  39 
illumination  of,  39 
injections  of,  26 

irrigation  of,  in  urethritis,  29,  45 
of  anterior,  28 
of  posterior,  31 
micro-organisms  of,  7 
Urethral  and  intravesical  irrigation,  28 
fever,  154 

follicles,  inflammation  of,  68 
spasm  (spasmodic  stricture),  107 
Urethritis,   acute,  specific  and  non-spe- 
cific, 3 

bacteriology  of,  7 
definition  and  etiology,  3 
diagnosis  of,  17,  18 
duration  of,  18 
symptoms  of,  13 
treatment  of,  19 
treatment,  internal,  20 
treatment,  local,  25 
chronic,  37 

diagnosis,  38 
etiology,  37 
pathology,  37 
symptoms,  38 
treatment,  internal,  42 
treatment,  local,  43 
Urethrocystitis,  89,  92 
Urethrorrhoaa  ex  libidine,  81 
Urethroscopy,  39 

Urethrotomy,  external  perineal,  145 
with  a  guide,  146 
without  a  guide,  150 
internal,  134 
Urinary  fever,  154 

treatment  of,  156 
fistula,  153 
Urine,  extravasation  of,  152 

VAS  deferens,  ligation  of,  for  chronic  re- 
lapsing epididymitis,  106 
Vegetations  (see  Venereal  warts) 
Venereal  warts,  58 

treatment  for,  59 
Vesicular  syphilide,  271 

WARTS,  venereal,  58 

treatment,    59  * 


Date  Due 


CAT.    NO     ?3   233  PRINTED    IN    U.S.A. 


FAQUTY  f    I 


A     000502506    9 


Keyes  . 

Venereal  diseases 


wciUo 

Kkkv2 
1900 


Keyes , 

Venereal  diseases 


KhkvZ 
1900 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRAR 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


